The AHA Guidelines and Scientific Statements Handbook

Chapter 18 Valvular Heart Disease

Subnormal EF

Stable?

Yes No, or

initial study

Clinical eval

every

6–12 mo.

Echo every

12 mo.

Reevaluate

and echo

3 mo.

Stable?

Clinical evaluation + Echo

Symptoms?

Equivocal

Chronic severe aortic regurgitation

No symptoms

Symptoms

No Yes

Reevaluation

LV function?

LV dimensions?

Exercise test

RVG or MRI

Normal EF

SD < 45 mm or

DD < 60 mm

SD > 55 mm or

DD < 75 mm

SD 45–50 mm or

DD 60–70 mm

SD 50–55 mm or

DD 70–75 mm

Normal

Consider hemodynamic

response to exercise

Abnormal

EF borderline or uncertain

Class I

Class IIa

Class IIb

Class I AVR

Yes No, or

initial study

Clinical eval

every

6 mo.

Echo every

12 mo.

Reevaluate

and Echo

3 mo.

Yes

Stable?

Clinical eval

every 6 mo.

Echo every

6 mo.

Class I

Fig. 18.2 Management strategy for patients with chronic severe aortic regurgitation. Preoperative coronary angiography should be performed
routinely as determined by age, symptoms, and coronary risk factors. Cardiac catheterization and angiography may also be helpful when there
is discordance between clinical fi ndings and echocardiography. “Stable” refers to stable echocardiographic measurements. In some centers,
serial follow-up may be performed with RVG or MRI rather than echocardiography to assess LV volume and systolic function.
AVR, aortic valve replacement; DD, end-diastolic dimension; EF, ejection fraction; RVG, radionuclide ventriculography; MRI, magnetic
resonance imaging; SD, end-systolic dimension.

4 Surgery to repair the aortic root or replace the
ascending aorta is indicated in patients with bicus-
pid aortic valves if the diameter of the aortic root or
ascending aorta is greater than 5.0 cm* or if the rate
of increase in diameter is 0.5 cm per year or more.
(Level of Evidence: C) ESC recommendation, IIa (C)

for bicuspid valve with diameter of the aortic root

or ascending aorta ≥5.0 cm. Recommendations also

given for Marfan syndrome with aortic diameter

≥4.5 cm [I (C)] and for all other patients

tricuspid aortic valve with aortic diameter ≥5.5 cm

[IIa (C)]