Treatment of Aortic Regurgitation with Left Ventricular End Systolic Diameter >50 mm or Reduced LVEF

In asymptomatic patients with chronic severe aortic regurgitation, ventricular dimensions and systolic function define when intervention becomes necessary. This protocol covers the thresholds that trigger a recommendation for surgery and the considerations that guide choice of procedure.

Clinical Scenario & Intervention Thresholds

Surgery is indicated or may be considered when any of the following criteria are met in the setting of asymptomatic chronic severe AR:

LVESD >50 mm, or LVESDi >25 mm/m² (particularly with small body surface area <1.68 m²), or resting LVEF ≤50% Class I
LVESDi >22 mm/m², or LVESVi >45 mL/m², or resting LVEF ≤55% — when surgical risk is low Class IIb
Severe AR in patients already undergoing CABG or surgery of the ascending aorta Class I

Treatment Approach

Management centres on surgical intervention targeting the aortic valve. The standard approach, and the alternatives available in selected patients or specific surgical settings, are detailed in the full protocol — along with the criteria that determine which option applies.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1093/eurheartj/ehaf194

AV surgery is recommended in asymptomatic patients with severe AR and LVESD >50 mm or LVESDi >25 mm/m² [especially in patients with small body size (BSA <1.68 m²)] or resting LVEF ≤50%.

AV surgery may be considered in asymptomatic patients with severe AR and LVESDi >22 mm/m², or LVESVic >45 mL/m² [especially in patients with small body size (BSA <1.68 m²)], or resting LVEF ≤55%, if the surgical risk is low.

AV surgery is recommended in symptomatic and asymptomatic patients with severe AR undergoing CABG or surgery of the ascending aorta.

AV replacement is still the standard surgical approach in most AR cases.

AV repair should be considered in selected patients with severe AR at experienced centres, when durable results are expected.

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.

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