the acc/aha guidelines for management of aortic ... regurgitation. the 5 most controversial...

Robert O. Bonow, MD, MS

No Relationships to Disclose

Northwestern University Feinberg School of MedicineBluhm Cardiovascular Institute

Northwestern Memorial Hospital

The ACC/AHA Guidelinesfor Management of Aortic Insufficiency:

Pitfalls and Nuances

Robert O. Bonow, MD, MS

No Relationships to Disclose

Northwestern University Feinberg School of MedicineBluhm Cardiovascular Institute

Northwestern Memorial Hospital

The 5 Most ControversialRecommendations for AR Management

in the US and European Guidelines

www.acc.orgwww.americanheart.org

www.esc.org


The 5 most controversial recommendations:

• Evidence-based recommendations?

• Surgery for BAV with aortic aneurysms?

• The asymptomatic patient with severe AR?

• LV volume assessment: M-mode vs 3D?

• Selection of a valve prosthesis?

Aortic Regurgitation








In the absence of randomized clinical trials, virtually all of the recommendations for AR are based on expert consensus

--- Level of Evidence C

• Aortic / aortic root dilatation:Ao diameter >55 mmAo diameter >50 mm with

risk factors

Bicuspid aortic valves

Indications for aortic surgery

class I

class IIa


risk factors



class I

class IIa

New 2014


risk factors Rate of increase



class I

class IIa

class IIa



• Patients with criteria for AVR:Ao diameter >45 mm



class I

class IIa

class IIa

class IIa




class IIa



class I

class IIaclass IIa

class IIaclass IIa

class IIa class IIa

class IIa



class I

class IIaclass IIa

class IIaclass IIa

class IIa class IIa

>2 mm/yr≥5 mm/yr

class I• Aortic / aortic root dilatation:

Ao diameter >55 mmAo diameter >50 mm with





50 mm

• Aortic / aortic root dilatation:2008 valve disease GL2012 thoracic aortic GL2014 valve disease GL

50 mm

55 mm

2010 ACCF/AHA/ACR/ASA/SCA/SCAI/STS/SVM Guidelines for theDiagnosis and Management of Patients with Thoracic Aortic Disease

2014 AHA/ACC Guidelines for the Management of Patients with ValvularHeart Disease


• Symptomatic patients class I

Indications for valve replacement

Aortic regurgitation

class I

• Symptomatic patients• LV systolic dysfunction

class I

class I



class I

class I

• Symptomatic patients• LV systolic dysfunction• Patients undergoing CABG

class I

class I

class I



class I

class I

class I

• Symptomatic patients• LV systolic dysfunction• Patients undergoing CABG• Severe LV dilatation

class I

class I

class I



class IIa

class I

class I

class I

class IIa


LVSD >50 mm

class I

class I

class I



class IIa

class I

class I

class I

class IIa


LVSD >50 mm

class I

class I

class I



class IIa

class I

class I

class I

class IIa

New 2014

• Symptomatic patients• LV systolic dysfunction• Patients undergoing CABG• Severe LV dilatation • Progressive LV dilatation,

low risk for surgeryLVSD >50 mm

class I

class I

class I



class IIa

class IIb

class I

class I

class I

class IIa

class IIa



class I

class I

class I



class IIa

class IIb

class I

class I

class I

class IIa

class IIa

LVDD >70 mmLVDD >65 mm



class I

class I

class I



class IIa

class IIb

class I

class I

class I

class IIa

class IIa

LVDD >70 mmLVDD >65 mm

New 2014

Average hospital mortality: 8.8%

• Low volume centers: 13.0%

• High volume centers: 6.0%

Data from national Medicare database 1994-1999684 hospitals

142,488 AVRs

Medicare data

0

20

40

60

80

100

0 1 2 3 4 5Time (years)

100

80

60

40

20

00 2 4 6 8 10

Eve

nt-F

ree

Sur

viva

l(p

erce

nt)

Aortic RegurgitationCardiac Events Based on Severity of AR

1 3 5 7 9 11

66%

37%

from Detaint et al. J Am Coll Cardiol Img 2008;1:1-11

Mild

Moderate

Severe

79%

n=251





142,488 AVRs

Medicare data

0

20

40

60

80

100

0 1 2 3 4 5Time (years)

100

80

60

40

20

00 2 4 6 8 10

Eve

nt-F

ree

Sur

viva

l(p

erce

nt)


1 3 5 7 9 11

66%

79%

37%

Mild

Moderate

Severe

Mild ARModerate AR

Severe AR

<30 <1030-59 11-30≥60 ≥30

RVol (ml) ERO (mm2)






142,488 AVRs

Medicare data

0

20

40

60

80

100

0 1 2 3 4 5Time (years)

100

80

60

40

20

00 2 4 6 8 10

Sur

viva

l (p

erce

nt)


1 3 5 7 9 11

69%75%

92%Mild

Moderate

Severe

Mild ARModerate AR

Severe AR

<30 <1030-59 11-30≥60 ≥30

RVol (ml) ERO (mm2)


Multivariate analysis:Predictors of cardiac events

BNP OR 6.9 p=0.0001ERO OR 3.4 p=0.001LVESD OR 4.3 p=0.01LVEDD OR 2.1 p=0.09

HR B-Exp P value16.0 6.7 – 38.3 <0.000113.2 3.8 – 45.8 <0.000116.3 5.8 – 45.9 <0.0001

7.0 3.2 – 15.3 <0.00013.2 1.6 – 6.5 <0.001

HR B-Exp P value7.4 6.7 – 38.3 <0.0001

13.2 3.8 – 45.8 0.00016.1 2.0 – 19.1 0.002

Regurgitant fractionRegurgitant volume

LVEDVLVESV

LV mass

Univariate Multivariable

the acc/aha guidelines for management of aortic ... regurgitation. the 5 most controversial...

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