p.26 抽出テキスト

The morphology of the AV represents a critical aspect in the diagnosis and treatment of AR. Pure AR in the context of BAV uncommonly manifests with normal aortic diameters, being more often associated with a dilated ascending aorta and/or root. It is important to define the valve phenotype to determine the repair probability and long-term result of AV repair or AV-sparing procedures. The degree of symmetry is an important predictor of BAV reparability with better long-term results in more symmetric phenotypes.219–221

7.3 Medical therapy

Medical therapy, especially angiotensin-converting enzyme-inhibitors (ACE-Is) or dihydropyridine calcium channel blockers, may provide symptomatic improvement in individuals with chronic severe AR for whom surgery is not feasible or contraindicated. The value of ACE-Is or dihydropyridines in delaying surgery in the presence of moderate or severe AR in asymptomatic patients has not been established, and their use is not recommended for this indication. The use of betablockers increases the length of the diastole and therefore the RVol, and should be used with caution if indicated for another reason. However, beta-blockers can be used along with ACE-Is or angiotensin receptor blockers (ARBs) after surgery, if indicated (systolic HF or heart rate control).222,223

7.4 Indications for intervention

Acute severe AR usually requires immediate surgery depending on the aetiology, such as infective endocarditis or spontaneous, traumatic, or iatrogenic aortic dissection.5,8 Surgery for the treatment of chronic severe AR is indicated depending on symptoms and/or the effects of the RVol on LV size and function (see Recommendation Table 3 and Figure 5). The presence of associated aortic dilatation dictates surgery, irrespective of AR severity. When the patient is symptomatic and AR severe, surgery is recommended unless the anticipated surgical risk is prohibitive.224–228 Concomitant surgical treatment of severe AR is also recommended, irrespective of symptoms, in patients requiring CABG, ascending aorta surgery, or any other cardiac surgical procedures.229,230 For the asymptomatic patient with severe AR, indications for surgery are based on the degree of functional impairment of the LV [LVEF ≤50%, left ventricular end-systolic diameter (LVESD) >50 mm, or left ventricular end-systolic diameter indexed to body surface area (BSA) (LVESDi) >25 mm/m2, especially in those with small BSA (BSA <1.68 m2) and elderly patients with low ventricular compliance].226,228,231–234 If surgery is deemed low risk, there is observational evidence from echocardiographic studies that early intervention might be beneficial for long-term prognosis when LVEF is ≤55%, LVESDi is >22 mm/m2, and/or left ventricular end-systolic volume indexed to BSA (LVESVi) is >45 mL/m2.235–239 A volumetric cut-off value of LVESVi ≥43 mL/m2 using CMR was recently proposed to guide the management of asymptomatic patients240,241 and appears to have better predictive value than LV diameter.242 Surgery may also be discussed in selected low-risk asymptomatic patients with significant LV dilatation (left ventricular end-diastolic diameter >65 mm) and progressive increase of LV diameters and/or decrease of LVEF during follow-up. Exercise testing should be performed, when feasible, in patients with severe AR who do not report symptoms and do not meet criteria for surgery.212 AV replacement is still the standard surgical approach in most AR cases (see Section 14.1 regarding prosthesis type considerations). However, owing to a better understanding of the pathophysiology of the aortic root (see Supplementary data online, Figure S1) paralleled with favourable long-term results, valve-sparing aortic root replacement (VSARR) and AV repair are increasingly performed in centres with appropriate expertise (Figure 5).243–255 In patients with root enlargement and good tissue quality (i.e. pliable AV cusps with normal motion), a valve-sparing procedure has been demonstrated to be superior to the use of a composite valve graft (Bentall procedure) in terms of long-term mortality and overall morbidity (thromboembolism and endocarditis, with similar need for reoperation),250–253,255–257 and should be therefore favoured by experienced centres, in particular in patients with an estimated long life expectancy.258 Valve preservation or valve repair should also be considered for patients with BAV based on age, anatomical presentation, and centre experience (Figure 5).220,245,246,259

When performed by experienced surgeons in well-selected young individuals, pulmonary autograft implantation (Ross operation) may also be a good alternative to prosthetic valve replacement.260–263 TAVI may be considered at experienced centres for selected patients with AR who are ineligible for surgery. The use of non-dedicated transcatheter valves for this indication is off-label and associated with an increased risk of valve malpositioning and residual AR, with consecutively higher rates of second valve implantation (about 10%) or surgical conversion, as compared with TAVI in AS.264–268 Dedicated devices appear to minimize the risk of valve migration and residual AR in selected patients, but are associated with a high new permanent pacemaker implantation rate (24%).267–269 Aortic dilatation is closely linked to AR. Dedicated ESC Guidelines give guidance regarding the evaluation and management of aortic root and ascending aortic dilatation.8 The aortic phenotype (see Supplementary data online, Figure S1), degree and rate of progression of aortic dilatation, and the underlying aetiology all affect timing of surgery, with the main indication being maximum aortic diameter.270–272 Dilation of the aortic root, which typically occurs in Marfan syndrome and other patients with connective tissue disease, has a worse prognosis compared with isolated dilatation of the ascending aorta and requires closer surveillance.270–272 Surgery is recommended in all patients with a maximal aortic root or ascending aneurysm diameter of ≥55 mm. In the presence of additional risk factors, a threshold of 50 mm may be considered for selected low-risk patients treated at experienced centres.8 If the patient has an established indication for AV surgery (due to AR or AS), concomitant surgery of the aortic root or the ascending aorta should be considered at a diameter of ≥45 mm. This threshold has been more clearly demonstrated in patients with BAV and should also be based on the patient’s height273 or specific intraoperative findings, such as the shape and thickness of the aortic wall.

7.5 Follow-up

A multimodality imaging approach45,274 and biomarkers like BNP213,214 might help identify patients at increased risk of LV damage early and guide the appropriate timing of intervention. Yearly follow-up is recommended in asymptomatic patients with severe AR. Closer followup (3–6 months) is recommended for those approaching thresholds for surgery, or showing a progressive dilatation of the LV or decrease of LVEF. Cardiac magnetic resonance can be especially useful in such a setting. Patients with moderate AR should be followed on a yearly basis, with echocardiography performed every 2 years. When a dilated ascending aorta is initially diagnosed by TTE, a multislice electrocardiographic-triggered CCT/CMR scan is recommended Downloaded from academic.oup.com/eurheartj/article/46/44/4635/8234488 by guest on 07 October 2026