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...................................................................................... 4.3 Medical therapy Medical therapy, especially angiotensin-converting enzyme inhibitors (ACEI) or dihydropiridines, may provide symptomatic improvement in individuals with chronic severe aortic regurgitation in whom surgery is not feasible. The value of ACEI or dihydropiridine in delaying surgery in the presence of moderate or severe aortic regurgitation in asymptomatic patients has not been established and their use is not recommended for this indication.

In patients who undergo surgery but continue to suffer from heart failure or hypertension, ACEI, angiotensin receptor blockers (ARBs), and beta-blockers are useful.141,142 In patients with Marfan syndrome, beta-blockers remain the mainstay for medical treatment and reducing shear stress and aortic growth rate and should be considered before and after surgery.143145 While ARBs did not prove to have a superior effect when compared to beta-blockers, they may be considered as an alternative in patients intolerant to beta-blockers.146148 By analogy, while there are no studies that provide supporting evidence, it is common clinical practice to advise beta-blocker or ARBs in patients with bicuspid aortic valve if the aortic root and/or ascending aorta is dilated. Management of aortic regurgitation during pregnancy is discussed in section 13.

4.4 Serial testing

All asymptomatic patients with severe aortic regurgitation and normal LV function should be followed up at least every year. In patients with either a first diagnosis or with LV diameter and/or ejection fraction showing significant changes or approaching thresholds for

Ascending aortic surgery should be considered in patients who have aortic root disease with

maximal ascending aortic diameter: • >_55 mm in all patients. • >_45 mm in the presence of Marfan syndrome

and additional risk factorsd or patients with a TGFBR1 or TGFBR2 mutation (including LoeysDietz syndrome).e • >_50 mm in the presence of a bicuspid valve with additional risk factorsd or coarctation. IIa C When surgery is primarily indicated for the aortic valve, replacement of the aortic root or tubular ascending aorta should be considered when >_45 mm.f IIa C

BSA= body surface area; CABG = coronary artery bypass grafting; CCT= cardiac computed tomography; CMR= cardiac magnetic resonance; ECG= electrocardiogram; LV= left ventricle/left ventricular; LVEF = left ventricular ejection fraction; LVESD= left ventricular end-systolic diameter. aClass of recommendation. bLevel of evidence. cFor clinical decision making, dimensions of the aorta should be confirmed by ECG-gated CCT. dFamily history of aortic dissection (or personal history of spontaneous vascular dissection), severe aortic or mitral regurgitation, desire for pregnancy, uncontrolled systemic arterial hypertension and/or aortic size increase >3 mm/year (using serial echocardiography or CMR measurements at the same level of the aorta confirmed by ECG-gated CCT).

fConsidering age, BSA, aetiology of the valvular disease, presence of a bicuspid aortic valve, and intraoperative shape and thickness of the ascending aorta.

Management of patients with aortic regurgitation

Significant enlargement of ascending aortaa

Follow-up Surgeryb

LVEF ≤ 50% or LVESD > 50 mm (or > 25 mm/m2 BSA)

N

N

Y Y

Severe aortic regurgitation N

N Y

Symptoms Y

Figure 2 Management of patients with aortic regurgitation. BSA = body surface area; LV = left ventricle/left ventricular; LVESD = left ventricle end-systolic diameter; LVEF = left ventricular ejection fraction. aSee recommendations on indications for surgery in severe aortic regurgitation and aortic root disease for definition. bSurgery should also be considered if significant changes in LV or aortic size occur during follow-up.

ESC/EACTS 2021

eA lower threshold of 40 mm may be considered in women with low BSA, TGFBR2 mutation and severe extra-aortic features.130 Downloaded from academic.oup.com/eurheartj/article/43/7/561/6358470 by guest on 07 October 2026