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Natural history and management of chronic aortic regurgitation in adults

Author
William H Gaasch, MD
Section Editor
Catherine M Otto, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC

INTRODUCTION

In most patients with chronic aortic regurgitation (AR), the disease evolves in a slow and insidious manner with a very low morbidity during a long asymptomatic phase. While some patients with mild AR do not progress for decades, others exhibit progression of the regurgitant lesion with the gradual development of severe AR with subsequent left ventricular dilation, systolic dysfunction, and eventually heart failure (table 1). (See 'Natural history' below.)

The volume load that burdens the left ventricle in patients with chronic AR leads to a series of compensatory myocardial and circulatory adjustments that can be affected by pharmacologic therapy and reversed by valve replacement. Thus, the management of patients with this disorder requires an understanding of the natural history of the disease, the limited role of medical therapy, and the timing of surgery [1].

This topic will review the management and prognosis of chronic AR. The pathophysiology, major clinical features, and surgical treatment of chronic AR and issues related to acute AR in adults are discussed separately. (See "Clinical manifestations and diagnosis of chronic aortic regurgitation in adults" and "Acute aortic regurgitation in adults".)

NATURAL HISTORY

Chronic aortic regurgitation (AR) generally evolves slowly with a long asymptomatic compensated phase with some patients developing worsening regurgitation that may progress to severe AR with left ventricular (LV) dilation, LV systolic dysfunction, and heart failure (table 1).

Data from case series of patients with chronic AR have been used to develop criteria to define compensated and decompensated phases of chronic severe AR (table 2A-B):

                      

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Literature review current through: Nov 2016. | This topic last updated: Wed Jul 29 00:00:00 GMT+00:00 2015.
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References
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  1. Gaasch WH, Sundaram M, Meyer TE. Managing asymptomatic patients with chronic aortic regurgitation. Chest 1997; 111:1702.
  2. Siemienczuk D, Greenberg B, Morris C, et al. Chronic aortic insufficiency: factors associated with progression to aortic valve replacement. Ann Intern Med 1989; 110:587.
  3. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.
  4. Bonow RO, Rosing DR, McIntosh CL, et al. The natural history of asymptomatic patients with aortic regurgitation and normal left ventricular function. Circulation 1983; 68:509.
  5. Bonow RO, Lakatos E, Maron BJ, Epstein SE. Serial long-term assessment of the natural history of asymptomatic patients with chronic aortic regurgitation and normal left ventricular systolic function. Circulation 1991; 84:1625.
  6. Henry WL, Bonow RO, Borer JS, et al. Observations on the optimum time for operative intervention for aortic regurgitation. I. Evaluation of the results of aortic valve replacement in symptomatic patients. Circulation 1980; 61:471.
  7. Dujardin KS, Enriquez-Sarano M, Schaff HV, et al. Mortality and morbidity of aortic regurgitation in clinical practice. A long-term follow-up study. Circulation 1999; 99:1851.
  8. Pichard AD, Smith H, Holt J, et al. Coronary vascular reserve in left ventricular hypertrophy secondary to chronic aortic regurgitation. Am J Cardiol 1983; 51:315.
  9. Basta LL, Raines D, Najjar S, Kioschos JM. Clinical, haemodynamic, and coronary angiographic correlates of angina pectoris in patients with severe aortic valve disease. Br Heart J 1975; 37:150.
  10. Chaliki HP, Mohty D, Avierinos JF, et al. Outcomes after aortic valve replacement in patients with severe aortic regurgitation and markedly reduced left ventricular function. Circulation 2002; 106:2687.
  11. Gabriel RS, Renapurkar R, Bolen MA, et al. Comparison of severity of aortic regurgitation by cardiovascular magnetic resonance versus transthoracic echocardiography. Am J Cardiol 2011; 108:1014.
  12. Goffinet C, Kersten V, Pouleur AC, et al. Comprehensive assessment of the severity and mechanism of aortic regurgitation using multidetector CT and MR. Eur Radiol 2010; 20:326.
  13. Debl K, Djavidani B, Buchner S, et al. Assessment of the anatomic regurgitant orifice in aortic regurgitation: a clinical magnetic resonance imaging study. Heart 2008; 94:e8.
  14. Søndergaard L, Aldershvile J, Hildebrandt P, et al. Vasodilatation with felodipine in chronic asymptomatic aortic regurgitation. Am Heart J 2000; 139:667.
  15. Shen WF, Roubin GS, Hirasawa K, et al. Noninvasive assessment of acute effects of nifedipine on rest and exercise hemodynamics and cardiac function in patients with aortic regurgitation. J Am Coll Cardiol 1984; 4:902.
  16. Shah RM, Singh M, Bhuriya R, et al. Favorable effects of vasodilators on left ventricular remodeling in asymptomatic patients with chronic moderate-severe aortic regurgitation and normal ejection fraction: a meta-analysis of clinical trials. Clin Cardiol 2012; 35:619.
  17. Elder DH, Wei L, Szwejkowski BR, et al. The impact of renin-angiotensin-aldosterone system blockade on heart failure outcomes and mortality in patients identified to have aortic regurgitation: a large population cohort study. J Am Coll Cardiol 2011; 58:2084.
  18. Scognamiglio R, Fasoli G, Ponchia A, Dalla-Volta S. Long-term nifedipine unloading therapy in asymptomatic patients with chronic severe aortic regurgitation. J Am Coll Cardiol 1990; 16:424.
  19. Scognamiglio R, Rahimtoola SH, Fasoli G, et al. Nifedipine in asymptomatic patients with severe aortic regurgitation and normal left ventricular function. N Engl J Med 1994; 331:689.
  20. Lin M, Chiang HT, Lin SL, et al. Vasodilator therapy in chronic asymptomatic aortic regurgitation: enalapril versus hydralazine therapy. J Am Coll Cardiol 1994; 24:1046.
  21. Evangelista A, Tornos P, Sambola A, et al. Long-term vasodilator therapy in patients with severe aortic regurgitation. N Engl J Med 2005; 353:1342.
  22. Greenberg B, Massie B, Bristow JD, et al. Long-term vasodilator therapy of chronic aortic insufficiency. A randomized double-blinded, placebo-controlled clinical trial. Circulation 1988; 78:92.
  23. Sampat U, Varadarajan P, Turk R, et al. Effect of beta-blocker therapy on survival in patients with severe aortic regurgitation results from a cohort of 756 patients. J Am Coll Cardiol 2009; 54:452.
  24. Bonow RO, Cheitlin MD, Crawford MH, Douglas PS. Task Force 3: valvular heart disease. J Am Coll Cardiol 2005; 45:1334.
  25. Mitchell JH, Haskell W, Snell P, Van Camp SP. Task Force 8: classification of sports. J Am Coll Cardiol 2005; 45:1364.
  26. Bekeredjian R, Grayburn PA. Valvular heart disease: aortic regurgitation. Circulation 2005; 112:125.
  27. Meijboom WB, Mollet NR, Van Mieghem CA, et al. Pre-operative computed tomography coronary angiography to detect significant coronary artery disease in patients referred for cardiac valve surgery. J Am Coll Cardiol 2006; 48:1658.
  28. Scheffel H, Leschka S, Plass A, et al. Accuracy of 64-slice computed tomography for the preoperative detection of coronary artery disease in patients with chronic aortic regurgitation. Am J Cardiol 2007; 100:701.
  29. Daniel WG, Hood WP Jr, Siart A, et al. Chronic aortic regurgitation: reassessment of the prognostic value of preoperative left ventricular end-systolic dimension and fractional shortening. Circulation 1985; 71:669.
  30. Carabello BA, Usher BW, Hendrix GH, et al. Predictors of outcome for aortic valve replacement in patients with aortic regurgitation and left ventricular dysfunction: a change in the measuring stick. J Am Coll Cardiol 1987; 10:991.
  31. Detaint D, Maalouf J, Tribouilloy C, et al. Congestive heart failure complicating aortic regurgitation with medical and surgical management: a prospective study of traditional and quantitative echocardiographic markers. J Thorac Cardiovasc Surg 2008; 136:1549.
  32. Forman R, Firth BG, Barnard MS. Prognostic significance of preoperative left ventricular ejection fraction and valve lesion in patients with aortic valve replacement. Am J Cardiol 1980; 45:1120.
  33. Greves J, Rahimtoola SH, McAnulty JH, et al. Preoperative criteria predictive of late survival following valve replacement for severe aortic regurgitation. Am Heart J 1981; 101:300.
  34. Bhudia SK, McCarthy PM, Kumpati GS, et al. Improved outcomes after aortic valve surgery for chronic aortic regurgitation with severe left ventricular dysfunction. J Am Coll Cardiol 2007; 49:1465.
  35. Stone PH, Clark RD, Goldschlager N, et al. Determinants of prognosis of patients with aortic regurgitation who undergo aortic valve replacement. J Am Coll Cardiol 1984; 3:1118.
  36. Klodas E, Enriquez-Sarano M, Tajik AJ, et al. Optimizing timing of surgical correction in patients with severe aortic regurgitation: role of symptoms. J Am Coll Cardiol 1997; 30:746.
  37. Carabello BA. Is it ever too late to operate on the patient with valvular heart disease? J Am Coll Cardiol 2004; 44:376.
  38. Gaasch WH, Carroll JD, Levine HJ, Criscitiello MG. Chronic aortic regurgitation: prognostic value of left ventricular end-systolic dimension and end-diastolic radius/thickness ratio. J Am Coll Cardiol 1983; 1:775.
  39. Kumpuris AG, Quinones MA, Waggoner AD, et al. Importance of preoperative hypertrophy, wall stress and end-systolic dimension as echocardiographic predictors of normalization of left ventricular dilatation after valve replacement in chronic aortic insufficiency. Am J Cardiol 1982; 49:1091.
  40. Bonow RO, Rosing DR, Maron BJ, et al. Reversal of left ventricular dysfunction after aortic valve replacement for chronic aortic regurgitation: influence of duration of preoperative left ventricular dysfunction. Circulation 1984; 70:570.
  41. Klodas E, Enriquez-Sarano M, Tajik AJ, et al. Surgery for aortic regurgitation in women. Contrasting indications and outcomes compared with men. Circulation 1996; 94:2472.
  42. Tornos P, Sambola A, Permanyer-Miralda G, et al. Long-term outcome of surgically treated aortic regurgitation: influence of guideline adherence toward early surgery. J Am Coll Cardiol 2006; 47:1012.