Aortic Valve Repair for Aortic Regurgitation (Podcast)

“When I’m managing a patient who needs surgery to treat aortic valve regurgitation, the fundamental first question I ask is: Can we save the valve?” says Cleveland Clinic cardiovascular imaging expert Milind Desai, MD, MBA. “The benefits of keeping the native valve with a repair outweigh anything else. When possible, a nature-made valve is better than a human-made valve.”

His cardiothoracic surgeon colleague Lars Svensson, MD, PhD, agrees. “In a study we did a few years ago evaluating treatment of aortic valve regurgitation in our patients with bicuspid aortic valves, the failure rate was the same out to 12 years between patients who had repairs and those who had replacement with biological valves,” notes Dr. Svensson, Chief of Cleveland Clinic’s Heart, Vascular & Thoracic Institute. “But beyond 12 years, the biological valves had a rapid dropoff in durability while the durability of the repaired valves held much more steady over time. So the durability of repair was very good, and repair also has the advantage of lower risks of stroke and infection.”

That’s one area of discussion between Drs. Desai and Svensson in a recent episode of Cleveland Clinic’s Cardiac Consult podcast, “Aortic Valve Repair for Aortic Regurgitation.” The two aortic valve experts bring their respective medical and surgical experience to bear to address a range of topics around aortic valve regurgitation, including:

• Symptoms and challenges in detecting aortic regurgitation
• Nuances of evaluation, including the role of advanced imaging
• The role of stress testing and CT imaging in asymptomatic patients
• Timing of surgical treatment and deciding between valve repair versus replacement
• Surgical techniques and outcomes, including for cases involving enlarged aortic roots
• Postoperative care and follow-up
• Management of mixed aortic valve disease

Click the podcast player above to listen to the 38-minute episode now or read on for an edited excerpt. Check out more Cardiac Consult episodes at clevelandclinic.org/cardiacconsultpodcast or wherever you get your podcasts.

Excerpt from the podcast

Lars Svensson, MD, PhD: One of the challenges in the surgical assessment of patients with aortic valve regurgitation, particularly when they are asymptomatic, is timing. We know that if patients go too long and develop scarring in the left ventricle based on MRI, their long-term results aren’t as good as they’d be if operated on sooner. We know it's often challenging to figure out whether or not patients are really having symptoms. What’s your current thinking about this?

Milind Desai, MD, MBA: In the current era of advanced multimodality imaging, we are fairly liberal in our thought process as we evaluate these patients. Of course, echo is absolutely the front line we use to quantify aortic valve insufficiency as well as to measure ejection fraction and volumes. We also routinely report strain because that has demonstrated some incremental prognostic value in these patients. If the degree of quantification does not jibe with the patient’s symptoms or there is eccentric jet or some similar finding, then we may go to transesophageal echo to further understand the findings. We also routinely use cardiac MRI, not only to assess the regurgitant fraction of the aortic valve leak but even more for left ventricular size, volumes and ejection fraction.

In fact, the guidelines talk about the size thresholds at which you need to refer asymptomatic individuals for cardiac surgery. But these guidelines are based on data that is more than two decades old in many cases, and on smaller series. A lot has evolved, including our surgical techniques, our ICU techniques and our imaging techniques.

So, a few years ago, we tackled the question of whether we can do better by studying more than 1,400 asymptomatic patients with significant aortic insufficiency at Cleveland Clinic. What we found was that if we waited until these patients got past the guideline-recommended size threshold, we waited too long. In fact, our thresholds were significantly lower for going to surgery, and these patients ended up doing well. Our findings were validated by a European cohort and by another large health system in the United States. Analyses of three different patient populations came to the same conclusion that we should be referring patients at a lower size threshold than is currently recommended by guidelines.

Dr. Svensson: I find that patients with mixed valve disease — in other words, aortic regurgitation and aortic stenosis — tend to be referred very late because people underestimate the disease. How do you currently evaluate patients with mixed aortic valve disease?

Dr. Desai: Mixed aortic stenosis and regurgitation is a complicated beast. Often physicians will be tracking one or the other and will neglect to pay enough attention to the other one. We recently published a study of patients with mixed aortic valve disease showing that if you wait for both lesions to get to a severe stage, then you have waited too long. In patients with moderate to moderately severe aortic stenosis and moderate to moderately severe aortic insufficiency, I generally would recommend an operation, especially if they have symptoms and other signs. It requires very careful assessment, symptom evaluation and imaging evaluation — often multimodality imaging evaluation.

Dr. Svensson: I agree. In mixed valve disease, the idea of waiting for either to become severe is usually too late. I’m always struck by how much better patients with mixed valve disease get after having an aortic valve replacement. These patients are obviously getting a replacement rather than a repair because of the calcification, and the results are really good. I find it interesting how symptomatic these patients often may be, even if they have moderate disease, both regurgitation and stenosis, as you pointed out.