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................................................................... these entities.4,101 The recommendations on indications for surgery in severe aortic regurgitation and aortic root disease may be related to symptoms, status of the LV, or dilatation of the aorta [see table of recommendations on indications for surgery in severe aortic regurgitation and aortic root or tubular ascending aortic aneurysm (irrespective of the severity of aortic regurgitation), and Figure 2].

In symptomatic patients, surgery is recommended irrespective of the LVEF as long as aortic regurgitation is severe and the operative risk is not prohibitive.105109 Surgery is recommended in symptomatic and asymptomatic patients with severe aortic regurgitation undergoing coronary artery bypass grafting (CABG), or surgery of the ascending aorta or another valve.110,111 In asymptomatic patients with severe aortic regurgitation, impairment of LV function [LVEF <_50% or left ventricular end-systolic diameter (LVESD) >50 mm] are associated with worse outcomes and surgery should therefore be pursued when these cut-offs are reached.107,108,112114 LVESD should be related to body surface area (BSA) and a cut-off of 25 mm/m2 BSA appeared to be more appropriate, especially in patients with small body size (BSA <1.68 m2) or with large BSA who are not overweight.108,115 Some recent retrospective, non-randomized studies emphasized the role of indexed LVESD and proposed a lower cut-off value of 20 or 22 mm/m2 BSA for the indexed LVESD.116118 One of these studies also suggests a higher cut-off value of 55% for LVEF.118 Based on these data, low-risk surgery may be discussed in some selected asymptomatic patients with LVESD >20 mm/m2 or resting LVEF between 50% and 55%. In patients not reaching the thresholds for surgery, close follow-up is needed, and exercise testing should be liberally performed to identify borderline symptomatic patients. Progressive enlargement of the LV, or a progressive decrease in its function in asymptomatic patients not reaching the thresholds for surgery but with significant LV dilatation [left ventricular end-diastolic diameter (LVEDD) >65 mm], may also be an appropriate indicator for timing operations in asymptomatic patients. TAVI may be considered in experienced centres for selected patients with aortic regurgitation and ineligible for SAVR.119,120 In patients with a dilated aorta, the rationale for surgery has been best defined in patients with Marfan syndrome and root dilation.121,122 Root aneurysms require root replacement, with or without preservation of the native aortic valve. In contrast, tubular ascending aortic aneurysms in the presence of normal aortic valves require only a supracommissural tube graft replacement. In patients with aortic diameters borderline indicated for aortic surgery, the family history, age, and anticipated risk of the procedure should be taken into consideration. Irrespective of the degree of aortic regurgitation and type of valve pathology, in patients with an aortic diameter >_55 mm with tricuspid or bicuspid aortic valves, ascending aortic surgery is recommended (see recommendations on indications for surgery in severe aortic regurgitation and aortic root disease) when the operative risk is not prohibitive.123125 In individuals with bicuspid aortic valve, when additional risk factors or coarctation126 are present, surgery should be considered when aortic diameter is >_50 mm.127129 In all patients with Marfan syndrome, aortic surgery is recommended for a maximal aortic diameter >_50 mm.5,121,122 When additional risk factors are present in patients with Marfan syndrome and in patients with a TGFBR1 or TGFBR2 mutation (including LoeysDietz syndrome), surgery should be considered at a maximal aortic diameter >_45 mm121,130 and even earlier (aortic diameter of The choice of the surgical procedure should be adapted according to the experience of the team, the presence of an aortic root aneurysm, characteristics of the cusps, life expectancy, and desired anticoagulation status.

Valve replacement is the standard procedure in the majority of patients with aortic regurgitation. Aortic valve-sparing root replacement and valve repair yield good long-term results in selected patients, with low rates of valve-related events as well as good quality of life131140 when performed in experienced centres. Aortic valve-sparing root replacement is recommended in younger patients who have an enlargement of the aortic root with normal cusp motion, when performed by experienced surgeons.133136,140 In selected patients, aortic valve repair132,132,137 or the Ross procedure138,139 may be an alternative to valve replacement, when performed by experienced surgeons.

Recommendations on indications for surgery in (A) severe aortic regurgitation and (B) aortic root or tubular ascending aortic aneurysm (irrespective of the severity of aortic regurgitation)

Indications for surgery Classa Levelb

A) Severe aortic regurgitation Surgery is recommended in symptomatic patients regardless of LV function.105109 I B Surgery is recommended in asymptomatic patients with LVESD >50 mm or LVESD >25 mm/m2 BSA (in patients with small body size) or resting LVEF <_50%.107,108,112,114,115 I B Surgery may be considered in asymptomatic patients with LVESD >20 mm/m2 BSA (especially in patients with small body size) or resting LVEF <_55%, if surgery is at low risk. IIb C Surgery is recommended in symptomatic and asymptomatic patients with severe aortic regurgitation undergoing CABG or surgery of the ascending aorta or of another valve. I C Aortic valve repair may be considered in selected patients at experienced centres when durable results are expected. IIb C B) Aortic root or tubular ascending aortic aneurysmc (irrespective of the severity of aortic regurgitation) Valve-sparing aortic root replacement is recommended in young patients with aortic root dilation, if performed in experienced centres and durable results are expected.133136,140 I B Ascending aortic surgery is recommended in patients with Marfan syndrome who have aortic root disease with a maximal ascending aortic diameter >_50 mm. I C

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40 mm or more) in women with low BSA, TGFBR2 mutation, and severe extra-aortic features.130 For patients who have an indication for aortic valve surgery, an aortic diameter ≥45 mm is considered to indicate concomitant surgery of the aortic root or tubular ascending aorta. The patient’s stature, the aetiology of the valvular disease (bicuspid valve), and the intraoperative shape and wall thickness of the ascending aorta should be considered for individual decisions.

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