Author: Stanley S Wang, MD, JD, MPH, Clinical Cardiologist, Austin Heart South; Assistant Professor of Medicine (Adjunct), University of North Carolina School of Medicine
Contributor Information and Disclosures
Updated: Jun 2, 2010
In acute severe aortic regurgitation (AR), surgical intervention is usuallyindicated, but the patient may be supported medically with dobutamine to augment cardiac output and shorten diastole and sodium nitroprusside to reduce afterload in hypertensive patients.
In chronic severe AR, vasodilator therapy may be used in select conditions to reduce afterload in patients with systolic hypertension to minimize wall stress and optimize LV function; in normotensive patients,vasodilator therapy is not likely to reduce regurgitant volume (preload) significantly and thus may not be of clinical benefit.22
The current American College of Cardiology/American Heart Association (ACC/AHA) guidelines say the following about vasodilator therapy:
• Vasodilator therapy is indicated for long-term therapy in patients with chronic, severe AR and symptoms of LV dysfunction but whoare not candidates for surgery.
• Vasodilator therapy is reasonable for short-term therapy in patients with severe LV dysfunction and heart failure symptoms to improve their hemodynamic profile before proceeding with surgery.
• Vasodilator therapy is acceptable for long-term therapy in asymptomatic patients with severe AR and LV dilation with normal EF.
However, under the currentguidelines, vasodilator therapy is not indicated for the following:
• Long-term therapy in asymptomatic patients with less than severe AR and normal EF
• Long-term therapy in asymptomatic patients with LV dysfunction who are candidates for surgery
• Long-term therapy in symptomatic patients with less than severe LV dysfunction who are candidates for surgery
Although diuretics,nitrates, and digoxin are sometimes used to help control symptoms in patients with AR, not enough data in the clinical literature justify routinely recommending or discouraging these therapies. Also, no data support drug therapy of any class in patients with less than severe AR.5
Antibiotic prophylaxis prior to dental procedures is no longer routinely recommended for all patients with AR under currentACC/AHA guidelines.5 However, select patient groups for whom prophylactic antibiotic therapy prior to dental procedures may be reasonable include the following:
• Patients with prosthetic material in their hearts (such as artificial valves or valves repaired with prosthetic material)
• Patients with prior infective endocarditis
• Patients with the following forms of congenitalheart disease (CHD):
o Cyanotic CHD that is incompletely or not repaired (including patients with palliative shunts and conduits)
o Repaired CHD using prosthetic material, for the first 6 months post-procedurally (ie, prior to endothelialization of the material)
o Repaired CHD but at risk of inhibited endothelialization (ie, with residual defects at or adjacent to thesite of the prosthetic material)
• Patients following cardiac transplantation who have valve regurgitation due to a structurally abnormal valve
Surgical treatment of AR usually requires replacement of the diseased valve with a prosthetic valve, although valve-sparing repair is increasingly possible with advances in surgical technique and technology.
Under current ACC/AHAguidelines5 , aortic valve surgery is recommended for patients with chronic severe AR under the following circumstances:
• Patient is symptomatic
• Patient is asymptomatic, with a resting EF of ≤ 55%
• Patient is asymptomatic, with LV dilation (LV end-systolic dimension >55 mm)
Additional circumstances in which aortic valve surgery may be reasonable include the following:...