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Review
. 2023 Oct;25(10):1373-1380.
doi: 10.1007/s11886-023-01955-x. Epub 2023 Sep 16.

Aortic Regurgitation: Review of the Diagnostic Criteria and the Management Guidelines

Maan Malahfji  1 , Mujtaba Saeed  2 , William A Zoghbi  2
Affiliations
Review

Aortic Regurgitation: Review of the Diagnostic Criteria and the Management Guidelines

Maan Malahfji et al. Curr Cardiol Rep. 2023 Oct.

Abstract

Purpose of review: The evaluation of aortic regurgitation (AR) has advanced from physical examination and angiography towards evidence based non-invasive quantitative methods, primarily with echocardiography and more recently with cardiac magnetic resonance (CMR). This review highlights the guidelines and recent evidence in the diagnosis and management of AR; and outlines future areas of research.

Recent findings: Contemporary large cohorts of AR patients studied with echocardiography and CMR suggest that the left ventricular remodeling and systolic function triggers for intervention may be lower than previously recommended in the guidelines and emphasize the importance of LV volumes in risk stratification. Important gaps of knowledge in the quantitation of AR severity and patient risk stratification were fulfilled recently. Potential thresholds for intervention using ventricular volumes and CMR quantitative findings were recently described. The criteria for what constitutes hemodynamically significant AR and the optimal timing of intervention AR deserve further study.

Keywords: Aortic regurgitation; Aortic valve surgery; Cardiac magnetic resonance; Echocardiography; Management guidelines.

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References

Papers of particular interest, published recently, have been highlighted as: •• Of major importance
    1. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2021;77:e25–197. - DOI - PubMed
    1. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. Circulation. 2008. https://doi.org/10.1161/CIRCULATIONAHA.108.190748 . - DOI - PubMed
    1. 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;84:1625–35. - DOI - PubMed
    1. •• Vejpongsa P, Xu J, Quinones MA, Shah DJ, Zoghbi WA. Differences in cardiac remodeling in left-sided valvular regurgitation: implications for optimal definition of significant aortic regurgitation. Cardiovasc Imaging. 2022;15:1730–1741. This CMR study demonstrated that patients with AR tend to have larger LV size and mass compared to patients with MR at similar Rvol and RF. Patients with AR who underwent surgery due to symptoms or LV remodeling had lower thresholds of Rvol and RF.
    1. •• Malahfji M, Crudo V, Kaolawanich Y, et al. Association ofcardiac remodeling with aortic regurgitation outcomes: the AR Consortium of the SCMR Registry. J Am Coll Cardiol. 2023. https://doi.org/10.1016/J.JACC.2023.03.001 . In this study of asymptomatic > moderate chronic AR patients with normal LVEF, quantitative CMR findings were associated with outcomes. LV volumes showed better prognostic value compared to LV diameters. The thresholds of Rvol and RF that demonstrated prognostic significance were also lower than thresholds recommended by guidelines.

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