Aortic Regurgitation Surgical Timing

Patrick T. O’Gara, MD

Brigham and Women’s Hospital

Harvard Medical School

Aortic Regurgitation Etiology

Valve

• BAV Disease

• Rheumatic

• IE

• Myxomatous

• Trauma

• Miscellaneous

Root

• CT Disorder

• Dissection

• IE

• Aortitis

• HTN

• Miscellaneous

Acute Severe AR

Average hospital mortality: 8.8%

• Low volume centers: 13.0%

• High volume centers: 6.0%

Data from national Medicare database 1994-1999

684 hospitals

142,488 AVRs

Medicare data

0

20

40

60

80

100

0 1 2 3 4 5Time (years)

100

80

60

40

20

0 0 2 4 6 8 10

Aliv

e, A

sym

pto

matic

with N

orm

al LV

Function (

%)

Asymptomatic with normal LV function

Aortic Regurgitation Natural History

1 3 5 7 9 11

Bonow et al. Circulation 1991;84:1625-1635

Tornos et al. Am Heart J 1995;130:333-339

Borer et al. Circulation 1998;97:525-534

64%

70%

54%

n 104 101 104

Annual risk 3.8% 3.1% 6.2%

Endpoints:

Symptoms 19 8 28

Asymp LVD 4 6 7 30% of endpoints occur

before onset of symptoms Death 2 0 4

• •

• • • •

Total 25 14 39

Bonow, J Am Coll Cardiol 2013;61:693-701

Severe AR: TTE Criteria

• Color jet width > 60%

• Vena contracta > 6 mm

• T1/2 AR CW < 200 msec

• TVI flow reversal (SSN): 13-15 cm

• RV > 60 mL

• ERO > 30 mm2

Aortic Regurgitation Survival and Function after AVR

Prognostic Factors

• Severity of pre-operative symptoms

• Severity of LV dysfunction

• Duration of LV dysfunction

Average hospital mortality: 8.8%

• Low volume centers: 13.0%

• High volume centers: 6.0%

Data from national Medicare database 1994-1999

684 hospitals

142,488 AVRs

Medicare data

0

20

40

60

80

100

0 1 2 3 4 5Time (years)

100

80

60

40

20

0 0 2 4 6 8 10

Event-

Fre

e S

urv

ival

(perc

ent)

Aortic Regurgitation Cardiac Events Based on Severity of AR

1 3 5 7 9 11

66%

79%

37%

Mild

Moderate

Severe

Mild AR

Moderate AR

Severe AR

<30 <10

30-59 11-30

≥60 ≥30

RVol (ml) ERO (mm2)

from Detaint et al. J Am Coll Cardiol Img 2008;1:1-11

BNP and Outcome in Aortic Regurgitation

Pizarro et al, J Am Coll Cardiol 2011;58:1701-1714

0

20

40

60

80

100

0 1 2 3 4

100

80

60

40

20

0

Event-

Fre

e S

urv

ival (%

)

Time (years)

0 1 2 3 4 5

BNP <130 pg/ml

p<0.001 BNP ≥130 pg/ml

BNP OR 6.9 p=0.0001

ERO OR 3.4 p=0.001

LVESD OR 4.3 p=0.01

LVEDD OR 2.1 p=0.09

Multivariate analysis:

Predictors of cardiac events

Aortic Regurgitation: Medical Therapy

Recommendations COR LOE

Treatment of hypertension (systolic BP >140 mm

Hg) is recommended in patients with chronic AR

(stages B and C), preferably with dihydropyridine

calcium channel blockers or angiotensin-

converting enzyme (ACE) inhibitors/angiotensin-

receptor blockers (ARBs)

I B

Medical therapy with ACE inhibitors/ARBs and

beta blockers is reasonable in patients with

severe AR who have symptoms and/or LV

dysfunction (stages C2 and D) when surgery is

not performed because of comorbidities

IIa B

Recommendations COR LOE

AVR is indicated for symptomatic patients with

severe AR regardless of LV systolic function

(stage D) I B

AVR is indicated for asymptomatic patients with

chronic severe AR and LV systolic dysfunction

(LVEF <50%) (stage C2) I B

AVR is indicated for patients with severe AR (stage

C or D) who are undergoing other cardiac surgery I C

Aortic Regurgitation: Intervention

Recommendations COR LOE

AVR is reasonable for asymptomatic patients

with severe AR with normal LV systolic

function (LVEF 50%), but severe LV dilation

(stage C2, LVESD >50 mm)

IIa B

AVR is reasonable in patients with moderate AR

(stage B) who are undergoing other cardiac

surgery

IIa C

AVR may be considered for asymptomatic

patients with severe AR and normal LV systolic

function (stage C1, LVEF ≥50%) but severe LV

dilation (LVEDD >65 mm) if surgical risk is low*

IIb C

Aortic Regurgitation: Intervention

Aortic Regurgitation Long-Term Survival After AVR

0

20

40

60

80

100

0 2 4 6 8 10 12 14 16

Su

rviv

al

(pe

rce

nt)

Group A n=60

Group B n=110

p<0.01

Time (months)

Tornos et al J Am Coll Cardiol 2006;26:1309-1313

Guidelines +

Guidelines -

Pre-AVR Post-AVR

LV LV

LA

LA

Aortic

valve

Prosthetic

valve

Survival After AVR Pre-Operative LV Function

0

20

40

60

80

100

0 2 4 6 8 10 12 14 16 18 20

P < 0.001

Chaliki HP et al. Circulation 2002; 106:2687-93.

Years

Su

rviv

al

(%) EF > 0.50

EF < 0.35

EF 0.35-0.50

Peri-op mortality

Low EF 14%

Med EF 6.7%

Nml EF 3.7%

Kamath A R et al. Circulation 2009;120:S134-S138

AVR with EF < 0.35

Interstitial Fibrosis Effect of AVR

Villari B et al. Circulation 2009;120:2386-2392

BAV

Keane, M. G. et al. Circulation 2000;102:III-35-III-39

Measurement of Aortic Root

Aortic Dimensions Bicuspid vs. Tricuspid Aortic Valve

3.1

3.2

3.3

3.4

3.5

3.6

3.7

3.8

Sinus STJ Asc Ao

BAV

TRI

P < 0.01

P < 0.001

P < 0.001

Keane MG et al. Circulation 2000; 102 [suppl III]: III-35-III-39.

BAV Aortopathy

Cardiac MRI BAV Disease

Bicuspid Aortic Valve and Aortopathy:

Intervention Recommendations COR LOE

Operative intervention to repair the aortic sinuses or

replace the ascending aorta is indicated in patients

with a bicuspid aortic valve if the diameter of the

aortic sinuses or ascending aorta is greater than

5.5 cm

I B

Operative intervention to repair the aortic sinuses or

replace the ascending aorta is reasonable in patients

with bicuspid aortic valves if the diameter of the

aortic sinuses or ascending aorta is greater than

5.0 cm and a risk factor for dissection is present

(family history of aortic dissection or if the rate of

increase in diameter is ≥0.5 cm per year)

IIa C

Bicuspid Aortic Valve and Aortopathy:

Intervention

Recommendations COR LOE

Replacement of the ascending aorta is reasonable

in patients with a bicuspid aortic valve who are

undergoing aortic valve surgery because of

severe AS or AR (Sections 3.4 and 4.4) if the

diameter of the ascending aorta is greater than

4.5 cm

IIa C

Aortic Regurgitation Concluding Thoughts

• Medical therapy should focus on BP

• Etiology of AR may drive timing of surgery

• LV size thresholds for surgery have decreased

over time

• AVR can be considered in selected patients with

severe LV dysfunction (EF < 0.35)

• Aortic root size criteria have also changed for

patients with BAV disease and aortopathy

80

60

40

20

0

BN

P (

pg/m

L)

LV Mass Index (g/m2)

50 75 100 125 150 175 200

BNP correlates with:

r p value

LVMi 0.77 <0.001

LVEDVi 0.73 0.001

LVESVi 0.69 0.002

Age 0.53 0.01

Average hospital mortality: 8.8%

• Low volume centers: 13.0%

• High volume centers: 6.0%

Data from national Medicare database 1994-1999

684 hospitals

142,488 AVRs

Medicare data

0

20

40

60

80

100

0 1 2 3 4 5Time (years)

100

80

60

40

20

0 0 2 4 6 8 10

Surv

ival (

perc

ent)

Aortic Regurgitation Long-Term Survival After AVR

12

Group A

n=60

Tornos et al J Am Coll Cardiol 2006;26:1309-1313

p<0.01

14 16

Group B

n=110

Guidelines +

Guidelines -

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10 11

As

ym

pto

ma

tic

wit

h N

orm

al

LV

Fu

nc

tio

n (

pe

rce

nt)

58%

Bonow R et al. Circulation 1991; 84:1625-35

Borer J et al. Circulation 1998; 97:525-34

Time (years)

n 104 104

Annual Risk 3.8% 6.2%

45%

25% of endpoints occur

before onset of symptoms

Endpoints:

Symptoms 19 28

Asymp LVD 4 7

Death 2 4

Aortic Regurgitation Asymptomatic Patients with Normal

LV Function

Asymptomatic AR with Normal LV Function

Bonow, Circulation 1984,1991

Siemienczuk, Ann Intern Med 1989

Tornos, Am Heart J 1995

Borer, Circulation 1998

Tarasoutchi, J Am Coll Cardiol 2003

Factors predictive of symptoms and /or LV dysfunction:

• LV end-systolic dimension/volume

• LV end-diastolic dimension/volume

• LV ejection fraction with exercise

Indications for Aortic Valve Replacement for Chronic Aortic Regurgitation

• Symptomatic patients

• LV systolic dysfunction

• Patients undergoing CABG

class I

class I

class I

Indications for valve replacement

Aortic regurgitation

class I

class I

class I

• Symptomatic patients

• LV systolic dysfunction

• Patients undergoing CABG

• Severe LV dilatation

LVSD >50 mm

class I

class I

class I

Indications for valve replacement

Aortic regurgitation

class IIa

class I

class I

class I

class IIa

• Symptomatic patients

• LV systolic dysfunction

• Patients undergoing CABG

• Severe LV dilatation

• Progressive LV dilatation,

low risk for surgery

LVSD >50 mm

class I

class I

class I

Indications for valve replacement

Aortic regurgitation

class IIa

class IIb

class I

class I

class I

class IIa

class IIa

LVDD >70 mm LVDD >65 mm

Indications for Surgery

Valve Aorta

BAV Disease

Fazel SS et al. J Thorac Cardiovasc Surg 2008; 135: 901-7

Aortic Regurgitation

Cardiac Events Based on AR Severity

0

20

40

60

80

100

0 1 2 3 4 5 6 7 8 9 10

Detaint et al. J Am Coll Cardiol Img 2008;1:1-11

Mild

Eve

nt-

Fre

e S

urv

iva

l

(perc

en

t)

Time (years)

Moderate 79%

66%

37%

Severe

Mild AR

Moderate AR

Severe AR

Rvol ERO

< 30 < 10

30-59 11-30

≥ 60 ≥ 30

Aortic Regurgitation Survival After Aortic Valve Replacement

0

20

40

60

80

100

0 1 2 3 4

Su

rviv

al

(pe

rce

nt)

Forman et al, Am J Cardiol 1980;45:1120-1125

LVEF > 50%

LVEF < 50%

p<0.02

Time (years)