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Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 February 2, 2021 e107 CLINICAL STATEMENTS AND GUIDELINES 4.3.3 Timing of Intervention Recommendations for Timing of Intervention for Chronic AR Referenced studies that support the recommendations are summarized in Online Data Supplement 15 to 17. COR LOE Recommendations 1 B-NR 1. In symptomatic patients with severe AR (Stage D), aortic valve surgery is indicated regardless of LV systolic function.1–7 1 B-NR 2. In asymptomatic patients with chronic severe AR and LV systolic dysfunction (LVEF ≤55%) (Stage C2), aortic valve surgery is indicated if no other cause for systolic dysfunction is identified.3,5,8–12 1 C-EO 3. In patients with severe AR (Stage C or D) who are undergoing cardiac surgery for other indications, aortic valve surgery is indicated. 2a B-NR 4. In asymptomatic patients with severe AR and normal LV systolic function (LVEF >55%), aortic valve surgery is reasonable when the LV is severely enlarged (LVESD >50 mm or indexed LVESD >25 mm/m2) (Stage C2).10,11,13–24 2a C-EO 5. In patients with moderate AR (Stage B) who are undergoing cardiac or aortic surgery for other indications, aortic valve surgery is reasonable. 2b B-NR 6. In asymptomatic patients with severe AR and normal LV systolic function at rest (LVEF >55%; Stage C1) and low surgical risk, aortic valve surgery may be considered when there is a progressive decline in LVEF on at least 3 serial studies to the low–normal range (LVEF 55% to 60%) or a progressive increase in LV dilation into the severe range (LV enddiastolic dimension [LVEDD] >65 mm).12,16,17,20,25–28 3: Harm B-NR 7. In patients with isolated severe AR who have indications for SAVR and are candidates for surgery, TAVI should not be performed.29–32 Synopsis Most patients with indications for surgery for chronic severe AR require valve replacement with a mechanical or bioprosthetic valve (Figure 4). Preservation of the native aortic valve (“valve sparing”) may be possible in selected patients with favorable valve anatomy who are undergoing surgical replacement of the aortic sinuses and/or ascending aorta.33–39 Although advances are occurring in primary aortic valve repair,37,40–42 this approach is not yet generalizable, and durability is not known. Current recommendations for AVR related to severity of LV dilation are based on measurement of LV short-axis diameters. There are limited data demonstrating prognostic value of LV volume measurements in chronic AR using left ventriculography,43 2D echocardiography,18,44 and CMR.45,46 Normal limits for LV volumes have been determined, as have criteria for severe LV dilation, but these values differ between 2D echocardiography, 3D echocardiography, and CMR,47,48 and there are insufficient data on the relationship between LV volumes and outcomes of patients with AR. This is an area in need of further investigation. Other markers of LV dysfunction and remodeling, such as global longitudinal strain and circulation biomarkers,44,46,49–51 likewise require additional clinical outcome studies. Recommendation-Specific Supportive Text 1. Symptoms are an important indication for AVR in patients with chronic severe AR, and the most important aspect of the clinical evaluation is taking a careful, detailed history to elicit symptoms or diminution of exercise capacity. Patients with chronic severe AR who develop symptoms have a high risk of death if AVR is not performed,52 and survival and functional status after AVR are related to the severity of preoperative symptoms, assessed either subjectively or objectively with exercise testing.1–4 Even among symptomatic patients with a severe reduction in LVEF (<35%), AVR results in improved survival rate.5–7 2. LV systolic function is an important determinant of survival and functional status after AVR.3–5,8,9,12,53–61 Outcomes are optimal when surgery is performed before LVEF decreases below 55%.16,25,26 In asymptomatic patients with LV systolic dysfunction, postoperative outcomes are better if AVR is performed before onset of symptoms.53 3. Patients with chronic severe AR may be referred for other types of cardiac surgery, such as CABG, mitral valve surgery, or surgery for correction of dilation of the aortic root or ascending aorta. In these patients, AVR will prevent both the hemodynamic consequences of persistent AR during the perioperative period and the possible need for a second cardiac operation in the near future. Patients undergoing surgical repair or replacement of the aortic root or ascending aorta may be candidates for aortic valve–sparing procedures.33–39 4. LVESD in patients with chronic AR reflects both the severity of the LV volume overload and the degree of LV systolic shortening.54,62 An elevated LVESD often reflects LV systolic dysfunction with a depressed LVEF. If LVEF is normal, an increased LVESD indicates a significant degree of LV remodeling and is associated with subsequent development of symptoms and/or LV systolic dysfunction and an increased mortality rate after AVR.17,20,21 Most studies have used unadjusted LVESD, but indexing for body size is important, particularly in women or small patients.13,19,52 Recent data indicate that the LVESD index threshold for optimal postoperative survival may be even smaller than 25 mm/m2,14–16 but more outcome data, and ideally an RCT, of earlier intervention are needed. Downloaded from http://ahajournals.org by on October 7, 2026