Aortic regurgitation: are we operating too late?

Chronic, severe aortic regurgitation (AR) imposes significant volume and pressure overload on the left ventricle (LV), resulting in compensatory, but eventually detrimental structural changes in the myocardium, with patients remaining asymptomatic for a long time. However, the LV eventually fails to maintain this compensated state, with a resultant drop in left ventricular ejection fraction (LVEF) and symptom onset. The current guidelines recommend aortic valve (AV) surgery in symptomatic patients or those with depressed LVEF as a Class I indication (1,2). The guidelines also recommend pre-emptive AV surgery (Class II indication) in asymptomatic patients with preserved LVEF, in the setting of a significantly dilated LV (1,2). However, these recommendations were derived mostly from small studies, with relatively short-term follow-up, performed more than two decades ago at a time when surgical mortality and morbidity were higher than what is seen today (3-6)