Treating aortic regurgitation: surgery, valves, and timing

When monitoring is the right strategy

For mild to moderate aortic regurgitation, or for certain severe asymptomatic cases without significant impact on the left ventricle, regular monitoring is the recommended strategy. It relies on echocardiograms performed at intervals defined by the severity of the leak, as assessed with your cardiologist.

At each check-up, several parameters are compared to previous exams: the diameter of the left ventricle, the ejection fraction, and changes in the regurgitation volume. It is the comparison over time, rather than an isolated value, that allows for the detection of progression. When certain thresholds are exceeded or symptoms appear, the management strategy may shift toward a surgical indication.

Criteria leading to surgery

The decision to operate is based on a combined analysis of several criteria, evaluated using the entire medical record. Three main situations lead to considering an intervention.

• Severe symptomatic aortic regurgitation: the onset of shortness of breath during exertion, significant fatigue, or chest pain in the context of severe AR is a clear indication for surgery. ‍
• Severe asymptomatic aortic regurgitation with impact on the left ventricle: even in the absence of symptoms, excessive dilation of the ventricle or a drop in the ejection fraction below certain thresholds may lead to an indication for surgery. ‍
• Aortic regurgitation associated with dilation of the ascending aorta: when the leak is linked to dilation of the major artery, a combined surgical procedure on both the valve and the aorta may be necessary. This specific case requires specialized surgical expertise.

Conventional open-heart surgery remains the standard approach for aortic valve replacement in cases of aortic regurgitation. TAVI (transcatheter aortic valve implantation, performed without opening the chest), which is widely used for aortic stenosis, is not currently a standard option for aortic regurgitation, except in very specific situations studied in expert centers.

The question "is it really the right time for surgery?" is one of the most common in this condition. A second opinion allows for a full review of the medical file, ensuring that all criteria have been considered and providing clarity before committing to a surgical decision.

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Mechanical valve or biological valve: understanding the trade-offs

When surgery is indicated, choosing the type of valve prosthesis is a personalized decision. There is no universal answer: the patient's age, lifestyle, comorbidities, and personal preferences all play a role.

• Mechanical valve: very durable, but requires lifelong anticoagulant treatment (regular INR monitoring, daily constraints, and managing the risk of bleeding). Generally offered to younger patients. ‍
• Biological valve: does not require long-term anticoagulants, but may eventually require reoperation due to progressive tissue degradation. Generally offered to older patients. ‍
• Aortic valve repair (conservative surgery): in certain specific cases, particularly some forms of bicuspid valve, it is possible to repair the valve rather than replace it. This technique is reserved for specific profiles and expert surgical teams. It is worth exploring and discussing with the surgical team.

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This decision is deeply personal. Expert advice can help clarify your options through a personalized analysis of your case before you commit to a decision that will have real-world consequences for your daily life.

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