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©2013 UpToDate ® Print Email ACC/AHA Guideline Summary: Indications for aortic valve replacement or repair (AVR) in chronic aortic regurgitation (AR) Class I - There is evidence and/orgeneral agreement that aortic valve replacement or repair (AVR) isindicated in patients with chronic AR in the following settings •  Symptomatic patients with severe chronic AR, irrespective of left ventricular ejection fraction (LVEF). •  If the presence of symptoms in patients with severe chronic AR is equivocal, the development of symptoms during an exercise test. •  Asymptomatic patients with severe chronic AR and an LVEF ≤50 percent at rest. •  Patients with severe chronic AR who undergo coronary artery bypass graft surgery (CABG) or surgery on the aorta or other heart valves. Class IIa - The weight of evidenceor opinion is in favor of the usefulness of AVR in patients withchronic AR in the following setting •  Asymptomatic patients with severe chronic AR and a normal LVEF (LVEF >50 percent) who have severe left ventricular dilatation (end-diastolic dimension >75 mm or end-systolic dimension >55 mm). Lower threshold values can be considered for patients of small stature. Class IIb - The weight of evidenceor opinion is less well established for the usefulness of AVR inpatients with chronic AR in the following settings •  Patients with moderate chronic AR who undergo CABG or surgery on the ascending aorta. •  Asymptomatic patients with severe chronic AR and an LVEF >50 percent in whom the end-diastolic dimension is >70 mm or the end-systolic dimension is >50 mm, and there is evidence of progressive left ventricular dilatation, declining exercise tolerance, or an abnormal hemodynamic response to exercise. Class III - There is evidence and/orgeneral agreement that AVR is NOT indicated in patients with chronic ARin the following setting •  Asymptomatic patients with mild, moderate, or severe chronic AR and an LVEF >50 percent at rest in whom the degree of left ventricular dilatation is not moderate or severe (end-diastolic dimension <70 mm or end-systolic dimension <50 mm).

Class III - There is evidence and/orgeneral agreement that AVR is NOT indicated in patients with chronic ARin the following setting •  Asymptomatic patients with mild, moderate, or severe chronic AR and an LVEF >50 percent at rest in whom the degree of left ventricular dilatation is not moderate or severe (end-diastolic dimension <70 mm or end-systolic dimension <50 mm). Data from Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). J Am Coll Cardiol 2006; 48:e1. ACC/AHA guideline summary: Indications for aortic valve repair or replacement (AVR) in adolescents or young adults with chronic aortic regurgitation (AR) Class I - There is evidence and/or generalagreement that aortic valve repair or replacement (AVR) is indicated inadolescents or young adults with chronic AR in the following settings •  Severe AR with symptoms of angina, syncope, or dyspnea on exertion •  Asymptomatic severe AR with a left ventricular ejection fraction (LVEF) less than 50 percent on serial studies separated by one to three months. •  Asymptomatic severe AR with progressive left ventricular enlargement to an end-diastolic dimension more than four standard deviations greater than normal. •  Coronary angiography before aortic valve surgery when a pulmonary autograft (Ross procedure) is considered when the origin of the coronary arteries was not identified by noninvasive testing. Class IIb - The weight of evidence oropinion is less well established for the usefulness of AVR inadolescents or young adults with chronic AR in the following settings •  Asymptomatic adolescents with severe AR who also have moderate aortic stenosis (peak left ventricle-to-peak aortic gradient greater than 40 mmHg at cardiac catheterization). •  Asymptomatic adolescents with severe AR who develop ST depression or T wave inversion over the left precordium.

Class IIb - The weight of evidence oropinion is less well established for the usefulness of AVR inadolescents or young adults with chronic AR in the following settings •  Asymptomatic adolescents with severe AR who also have moderate aortic stenosis (peak left ventricle-to-peak aortic gradient greater than 40 mmHg at cardiac catheterization). •  Asymptomatic adolescents with severe AR who develop ST depression or T wave inversion over the left precordium. Data from Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). J Am Coll Cardiol 2006; 48:e1.

Class III - There is evidence and/orgeneral agreement that AVR is NOT indicated in patients with chronic ARin the following setting •  Asymptomatic patients with mild, moderate, or severe chronic AR and an LVEF >50 percent at rest in whom the degree of left ventricular dilatation is not moderate or severe (end-diastolic dimension <70 mm or end-systolic dimension <50 mm). Data from Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). J Am Coll Cardiol 2006; 48:e1.