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February 2, 2021 Circulation. 2021;143:e72–e227. DOI: 10.1161/CIR.0000000000000923 e108

CLINICAL STATEMENTS AND GUIDELINES Otto et al 2020 ACC/AHA Guideline for the Management of Valvular Heart Disease

LV volumes may be a more sensitive predictor of cardiac events than LVESD index in asymptomatic patients,18 but more data are needed to determine the threshold values of LV systolic volume that best predict postoperative outcomes. 5.	 In patients with moderate AR who are undergoing other forms of cardiac surgery, such as CABG, mitral valve surgery, or replacement of the ascending aorta, the decision to intervene on the aortic valve concurrently includes consideration of several factors, including aortic valve anatomy, aortic root size and shape, regurgitant severity, other comorbidities, and patients’ preferences and values. Patients undergoing surgical repair or replacement of the aortic root or ascending aorta may be candidates for a valve-sparing procedure.33–39 6.	 LVEDD, a marker of the severity of LV volume overload in patients with chronic AR, is significantly associated with clinical outcomes in asymptomatic patients, and progressive increases in LVEDD are associated with subsequent need for surgery.16,17,20,25–28 In asymptomatic patients, it is important to ensure that apparent changes in LV size or LVEF are not due simply to measurement or physiological variability. In addition, confirmation of severe regurgitation by quantitative measures of AR severity with TTE, TEE, or, when needed, CMR provides confidence that AR is the cause of LV dilation or decrease in LVEF. When there is an apparent significant fall in EF or increase in LV size, repeat imaging typically is performed at 3- to 6-month intervals unless there is clinical deterioration. 7.	 TAVI for isolated chronic AR is challenging because of dilation of the aortic annulus and aortic root and, in many patients, lack of sufficient leaflet calcification. Risks of TAVI for treatment of AR include transcatheter valve migration and significant paravalvular leak.29–32 TAVI is rarely feasible, and then only in carefully selected patients with severe AR and HF who have a prohibitive surgical risk and in whom valvular calcification and annular size are appropriate for a transcatheter approach.

Figure 4. Timing of intervention for AR. Colors correspond to Table 2. AR indicates aortic regurgitation; AVR, aortic valve replacement; EDD, end-diastolic dimension; ERO, effective regurgitant orifice; LVEF, left ventricular ejection fraction; LVESD, left ventricular end-systolic dimension; RF, regurgitant fraction; RVol, regurgitant volume; and VC, vena contracta

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