Aortic regurgitation: quantitation and surgery timing

This page covers native aortic regurgitation (AR) in adults; ESC/EACTS 2025 says chronic AR is mainly due to intrinsic abnormalities of the valve cusps and/or progressive dilatation of the aortic root and/or ascending aorta.^[1] It covers causes, grading, the surgery triggers in each guideline, the aorta, transcatheter options, medical therapy, follow-up and acute AR. TAVI and SAVR for aortic stenosis are covered in Severe aortic stenosis: TAVI versus surgical valve replacement. Valve choice and antithrombotic therapy after replacement are covered in Prosthetic heart valves: choice, anticoagulation and thrombosis. The asymptomatic patient with severe aortic stenosis is covered in Asymptomatic severe aortic stenosis: exercise testing and surgery triggers.

What causes aortic regurgitation

ESC/EACTS 2025 says chronic AR is mainly due to intrinsic abnormalities of the aortic valve (AV) cusps and/or secondary to progressive dilatation of the aortic root and/or ascending aorta.^[1] In high-income countries, it says degenerative changes are the leading cause of AR, while rheumatic heart disease (RHD) is more frequent in middle- and low-income countries.^[1] Chronic pure severe AR is more frequent in men and is associated with a bicuspid aortic valve (BAV) and concomitant dilatation of the aorta in more than one-half of cases.^[1]

ACC/AHA 2020 gives the US view.^[3] It says the most common causes of chronic severe AR in the United States and other high-income countries are BAV disease and primary diseases of the ascending aorta or the sinuses of Valsalva.^[3] Rheumatic heart disease is the leading cause of AR in many low- to middle-income countries.^[3] With calcific valve disease, regurgitation often accompanies aortic stenosis (AS), but its degree usually is mild to moderate rather than severe.^[3]

^{[1] [3]}

Pathophysiology: a volume-loaded left ventricle

Chronic AR loads the left ventricle (LV) with volume, slowly.^[3] ACC/AHA 2020 says that in most patients the disease course is chronic and slowly progressive, with increasing LV volume overload and LV adaptation via chamber dilation and hypertrophy.^[3] Both guidelines write their surgery triggers in symptoms and in LV size and function.^[1][3]

ESC/EACTS 2025 says surgery for chronic severe AR is indicated depending on symptoms and/or the effects of the regurgitant volume (RVol) on LV size and function.^[1] ACC/AHA 2020 says LV end-systolic dimension (LVESD) in chronic AR reflects both the severity of the LV volume overload and the degree of LV systolic shortening.^[3] An elevated LVESD often reflects LV systolic dysfunction with a depressed LVEF.^[3] If LVEF is normal, an increased LVESD indicates a significant degree of LV remodelling and is associated with subsequent development of symptoms and/or LV systolic dysfunction and an increased mortality rate after AVR.^[3]

Acute AR behaves differently.^[3] ACC/AHA 2020 says the acute volume overload on the LV usually results in severe pulmonary congestion, as well as a low forward cardiac output.^[3]

Clinical presentation

Chronic AR can be severe without symptoms: ACC/AHA 2020 Table 15 calls Stage C asymptomatic severe AR.^[2] ACC/AHA 2020 Table 15 (Stages of Chronic AR) lists no symptoms in Stages A to C.^[2] Its Stage D (symptomatic severe AR) symptoms are exertional dyspnoea or angina or more severe heart failure (HF) symptoms.^[2]

Symptoms have to be hunted for.^[3] ACC/AHA 2020 says symptoms are an important indication for AVR in chronic severe AR, and the most important aspect of the clinical evaluation is taking a careful, detailed history to elicit symptoms or diminution of exercise capacity.^[3] ESC/EACTS 2025 adds that exercise testing should be performed, when feasible, in patients with severe AR who do not report symptoms and do not meet criteria for surgery.^[1] In Table 15, the Stage C symptom cell reads: none; exercise testing is reasonable to confirm symptom status.^[2]

Acute AR presents differently.^[3] ACC/AHA 2020 says the acute volume overload usually results in severe pulmonary congestion with a low forward cardiac output.^[3] In pregnancy, ESC 2025 says acute regurgitant lesions are often less well tolerated than chronic regurgitation.^[5]

Differential diagnosis: which AR, and is it the AR?

Once AR is found, the questions that change management are what is causing it, whether it is acute or chronic, whether the aorta is involved, and whether LV changes are really due to the AR.^[1][3]

• Cusp disease versus aortic disease (ESC/EACTS 2025). The mechanism of AR and the aortic diameters determine suitability for AV sparing or repair.^[1]
• BAV (ESC/EACTS 2025). Pure AR in the context of BAV uncommonly manifests with normal aortic diameters, being more often associated with a dilated ascending aorta and/or root.^[1]
• Endocarditis versus aortic dissection in acute AR (ACC/AHA 2020). Acute AR may come from valve abnormalities, most often endocarditis, or from abnormalities of the aorta, primarily aortic dissection; acute severe AR caused by aortic dissection is a surgical emergency.^[3]
• Acute coronary syndrome (ACC/AHA 2020). In acute AR, angiography should be considered only when the diagnosis cannot be determined by noninvasive imaging or when the differential diagnosis is an acute coronary syndrome.^[3]
• AR with calcific AS (ACC/AHA 2020). With calcific valve disease, regurgitation often accompanies AS, but its degree usually is mild to moderate rather than severe.^[3]
• Mixed aortic valve disease (ESC/EACTS 2025). Its severity is often underestimated, and patients with balanced moderate AR and AS show adverse event rates comparable to patients with severe isolated AS.^[1]
• Another cause for LV dysfunction (ACC/AHA 2020). The COR 1 row for LVEF of 55% or less in asymptomatic chronic severe AR applies if no other cause for systolic dysfunction is identified.^[3]
• Measurement noise (ACC/AHA 2020). In asymptomatic patients, it is important to ensure that apparent changes in LV size or LVEF are not due simply to measurement or physiological variability.^[3]

ACC/AHA 2020 adds that confirmation of severe regurgitation by quantitative measures with TTE, TEE or, when needed, CMR provides confidence that AR is the cause of LV dilation or a decrease in LVEF.^[3]

Bedside assessment

Listen, but do not rely on listening.^[3] ACC/AHA 2020 says auscultation has high specificity for detecting AR but low sensitivity and diagnostic accuracy.^[3] TTE can identify AR in patients who have been deemed to be at risk on the basis of known aortic dilation or a condition associated with abnormal aortic valve function, such as a BAV.^[3]

Record the blood pressure as part of the assessment.^[3][1] ACC/AHA 2020 says severe AR is associated with a wide pulse pressure.^[3] ESC/EACTS 2025 says the evaluation needs to take the haemodynamic condition into consideration, particularly the BP, since high pressures can lead to overestimation of the RVol.^[1] For acute severe AR resulting from IE or aortic dissection, ACC/AHA 2020 says medical therapy to reduce LV afterload may allow temporary stabilisation, but surgery should not be delayed, especially if there is hypotension, pulmonary oedema or evidence of low flow.^[3]

Investigations and grading severity

ESC/EACTS 2025 lists what a stepwise AR evaluation should address: the severity of AR, its mechanism and aetiology; the haemodynamic impact on LV function and pulmonary pressure; and evaluation of the ascending aorta.^[1] Echocardiography is the first-line modality, while cardiac magnetic resonance (CMR) and cardiac CT (CCT) are more accurate for the measurement of specific parameters.^[1] It says assessment of AR severity with TTE follows an integrative approach considering qualitative, semi-quantitative and quantitative parameters, but remains challenging.^[1]

ACC/AHA 2020: recommendations for diagnostic testing of chronic AR (all three rows)

^[3]

The ACC/AHA 2020 synopsis says TTE gives the aetiology and mechanism of AR (including valve reparability), the severity of regurgitation and the morphology of the ascending aorta.^[3] TTE also shows the LV response to the increases in preload and afterload, and TEE, CMR or aortic angiography add information when needed.^[3] Although qualitative measures are adequate in many situations, it says that when AR is significant (Stages B and C), quantitative measures of regurgitant volume and effective regurgitant orifice (ERO) area are better predictors of clinical outcome.^[3]

The echo grades: ACC/AHA 2020 Table 15

ACC/AHA 2020 Table 15 stages AR from patients at risk (Stage A) and progressive mild to moderate AR (Stage B) to severe asymptomatic (Stage C) and symptomatic (Stage D) AR.^[3][2] Each stage is defined by valve anatomy, valve haemodynamics, severity of LV dilation and LV systolic function, as well as by patient symptoms.^[3]

ACC/AHA 2020 Table 15: Stages of Chronic AR (all four stages)

^[2]

Read the severe column with its last line: in Stages C and D, Table 15 says the diagnosis of chronic severe AR also requires evidence of LV dilation.^[2] The table abbreviations include ERO, effective regurgitant orifice; IE, infective endocarditis; LVESD, left ventricular end-systolic dimension; and LVOT, left ventricular outflow tract.^[2]

ESC/EACTS 2025 Figure 4 (Imaging assessment of patients with aortic regurgitation) is printed as an image; its legend refers to Recommendation Table 3 for the specific cut-offs, which are given below.^[1]

^{[2] [3]}

CMR, 3D echo, strain and biomarkers

ESC/EACTS 2025 says consequences of AR on LV size and function must be carefully assessed, and that cut-offs for intervention are mostly based on two-dimensional (2D) echocardiographic measurements.^[1] However, 3D echocardiography and CMR allow more accurate evaluation of LV volumes and LVEF than 2D echocardiography, and are useful in borderline cases.^[1]

• CMR (ACC/AHA 2020). TTE and CMR are useful when clinical assessment and TTE severity disagree or TTE images are suboptimal; CMR provides accurate and reproducible measures of regurgitant volume and regurgitant fraction in AR, as well as aortic morphology, LV volume and LV systolic function.^[3]
• Catheterisation (ACC/AHA 2020). Cardiac catheterisation with LV and aortic angiography, as well as quantitation of regurgitation severity, is another option.^[3]
• LV volume by CMR (ESC/EACTS 2025). A cut-off of LVESVi ≥43 mL/m² using CMR was recently proposed to guide the management of asymptomatic patients and appears to have better predictive value than LV diameter.^[1]
• Echo or CMR for LVESVi (ESC/EACTS 2025). In the Recommendation Table 3 row for asymptomatic severe AR if the surgical risk is low (Class IIb, Level B), the LVESVi value of >45 mL/m² is measured using echocardiography or CMR (footnote c).^[1]
• Strain (ESC/EACTS 2025). Strain imaging can be helpful in identifying subclinical LV dysfunction and can therefore influence the optimal timing of intervention.^[1]
• Stress, BNP and fibrosis (ESC/EACTS 2025). Reduced longitudinal strain and contractile reserve at stress echocardiography, elevated biomarkers (BNP) and myocardial fibrosis on CMR need to be integrated in decision-making, even if not entirely validated yet.^[1]
• LV volumes (ACC/AHA 2020). Normal limits and criteria for severe LV dilation differ between 2D echocardiography, 3D echocardiography and CMR, and there are insufficient data on the relationship between LV volumes and outcomes in AR.^[3]

Imaging the aorta and the valve

ESC/EACTS 2025 says that, given its close relationship with AV function, accurate measurements of the aortic diameter are required at all levels: the annulus, sinuses of Valsalva, sinotubular junction and ascending aorta.^[1] The largest diameter is used to indicate the aortic phenotype: root phenotype, ascending phenotypes, and extended or mixed forms.^[1] When a dilated ascending aorta is first diagnosed by TTE, it recommends a multislice ECG-triggered CCT/CMR scan to confirm the maximal diameter, rule out isolated single sinus dilatation and provide a baseline reference.^[1]

Valve morphology matters for repair.^[1] ESC/EACTS 2025 says it is important to define the valve phenotype to determine the repair probability and long-term result of AV repair or AV-sparing procedures.^[1] The degree of symmetry is an important predictor of BAV reparability, with better long-term results in more symmetric phenotypes.^[1]

Management — acute severe AR

ESC/EACTS 2025 says acute severe AR usually requires immediate surgery depending on the aetiology, such as infective endocarditis or spontaneous, traumatic or iatrogenic aortic dissection.^[1] In its discussion of cardiogenic shock and acute heart failure, it says surgery represents the preferred treatment in acute AR, while TAVI has only been described in individual cases or patients with a failed surgical valve (valve-in-valve).^[1] Fast pacing over a temporary pacemaker lead shortens the diastole and may temporarily improve haemodynamics until the intervention.^[1]

Beta-blockers need thought in acute AR.^[3] ACC/AHA 2020 says beta blockers are often used in treating aortic dissection, but should be used very cautiously, if at all, for other causes of acute AR because they will block the compensatory tachycardia and could precipitate a marked reduction in blood pressure.^[3]

^{[3] [1]}

Management — chronic severe AR: when to operate

ESC/EACTS 2025 says that when the patient is symptomatic and AR severe, surgery is recommended unless the anticipated surgical risk is prohibitive.^[1] Concomitant surgical treatment of severe AR is also recommended, irrespective of symptoms, in patients requiring CABG, ascending aorta surgery or any other cardiac surgical procedure.^[1] In the asymptomatic patient with severe AR, it says surgery is based on the degree of LV functional impairment.^[1]

ESC/EACTS 2025 Recommendation Table 3: indications for intervention in severe aortic regurgitation (all eight rows)

^[1]

The narrative around the table adds detail.^[1] ESC/EACTS 2025 says the LVESDi threshold of >25 mm/m² applies especially in those with small BSA (below 1.68 m²) and in elderly patients with low ventricular compliance.^[1] If surgery is deemed low risk, it says observational evidence from echocardiographic studies suggests early intervention might be beneficial for long-term prognosis when LVEF is ≤55%, LVESDi is >22 mm/m² and/or LVESVi is >45 mL/m².^[1] Surgery may also be discussed in selected low-risk asymptomatic patients with significant LV dilatation (LV end-diastolic diameter >65 mm) and progressive increase of LV diameters and/or decrease of LVEF during follow-up (text; no class or level given).^[1]

ACC/AHA 2020: recommendations for timing of intervention for chronic AR (all seven rows)

^{[3] [1] [3]}

The strongest LVEF rows of the two guidelines sit at different thresholds.^[1][3] In asymptomatic severe AR, ESC/EACTS 2025 recommends AV surgery at a resting LVEF of 50% or less (Class I, Level B).^[1] It says AV surgery may be considered at a resting LVEF of 55% or less if the surgical risk is low (Class IIb, Level B).^[1] ACC/AHA 2020 says aortic valve surgery is indicated in asymptomatic chronic severe AR with an LVEF of 55% or less (Stage C2) if no other cause for systolic dysfunction is identified (COR 1, LOE B-NR).^[3] Its supportive text says outcomes are optimal when surgery is performed before LVEF decreases below 55%.^[3]

^{[3] [1]}

Why these thresholds

• Symptoms (ACC/AHA 2020). Patients with chronic severe AR who develop symptoms have a high risk of death if AVR is not performed; even among symptomatic patients with a severe reduction in LVEF (<35%), AVR results in an improved survival rate.^[3]
• Timing (ACC/AHA 2020). In asymptomatic patients with LV systolic dysfunction, postoperative outcomes are better if AVR is performed before the onset of symptoms.^[3]
• Diameters (ACC/AHA 2020). Current recommendations for AVR related to severity of LV dilation are based on measurement of LV short-axis diameters.^[3]
• Indexing (ACC/AHA 2020). Most studies used unadjusted LVESD, but indexing for body size is important, particularly in women or small patients.^[3]
• A lower index? (ACC/AHA 2020). Recent data indicate that the LVESD index threshold for optimal postoperative survival may be even smaller than 25 mm/m², but more outcome data, and ideally an RCT, of earlier intervention are needed.^[3]
• Volumes (ACC/AHA 2020). LV volumes may be a more sensitive predictor of cardiac events than the LVESD index in asymptomatic patients, but more data are needed to determine the LV systolic volume thresholds that best predict postoperative outcomes.^[3]
• LVEDD (ACC/AHA 2020). LVEDD, a marker of the severity of LV volume overload in chronic AR, is significantly associated with clinical outcomes in asymptomatic patients, and progressive increases in LVEDD are associated with subsequent need for surgery.^[3]
• Other cardiac surgery (ACC/AHA 2020). In patients with chronic severe AR referred for other cardiac surgery, AVR will prevent both the haemodynamic consequences of persistent AR during the perioperative period and the possible need for a second cardiac operation in the near future.^[3]

Which operation: replacement, repair or valve sparing

ESC/EACTS 2025 says AV replacement is still the standard surgical approach in most AR cases.^[1] ACC/AHA 2020 agrees that most patients with indications for surgery for chronic severe AR require valve replacement with a mechanical or bioprosthetic valve.^[3] Choosing between those prostheses is covered in Prosthetic heart valves: choice, anticoagulation and thrombosis.

Valve-sparing aortic root replacement (VSARR) and AV repair are increasingly performed in centres with appropriate expertise, according to ESC/EACTS 2025.^[1] In root enlargement with good tissue quality (pliable AV cusps with normal motion), it says a valve-sparing procedure has been demonstrated to be superior to a composite valve graft (Bentall procedure) in long-term mortality and overall morbidity (thromboembolism and endocarditis, with similar need for reoperation).^[1] It says the valve-sparing procedure should therefore be favoured by experienced centres, in particular in patients with an estimated long life expectancy.^[1]

• ESC/EACTS 2025, Class I, Level B. Valve-sparing aortic root replacement is recommended in young patients with aortic root dilatation at experienced centres, when durable results are expected.^[1]
• ESC/EACTS 2025, Class IIa, Level B. AV repair should be considered in selected patients with severe AR at experienced centres, when durable results are expected.^[1]
• BAV (ESC/EACTS 2025 text). Valve preservation or valve repair should also be considered for patients with BAV based on age, anatomical presentation and centre experience.^[1]
• Ross operation (ESC/EACTS 2025 text). When performed by experienced surgeons in well-selected young individuals, pulmonary autograft implantation may also be a good alternative to prosthetic valve replacement.^[1]
• Repair in the US view (ACC/AHA 2020 text). Preserving the native valve ("valve sparing") may be possible in selected patients with favourable valve anatomy undergoing surgical replacement of the aortic sinuses and/or ascending aorta; primary aortic valve repair is not yet generalisable, and durability is not known.^[3]

TAVI for aortic regurgitation

The 2025 ALIGN-AR report says transcatheter devices designed for calcific aortic stenosis are not optimised for use in native AR.^[7] The 2024 report adds that commercial transcatheter heart valves in pure AR are hampered by unacceptable rates of embolisation and paravalvular regurgitation.^[6] ACC/AHA 2020 says TAVI for isolated chronic AR is challenging because of dilation of the aortic annulus and aortic root and, in many patients, lack of sufficient leaflet calcification.^[3] It says the risks of TAVI for treatment of AR include transcatheter valve migration and significant paravalvular leak.^[3] It adds that TAVI is rarely feasible, and then only in carefully selected patients with severe AR and HF who have a prohibitive surgical risk and in whom valvular calcification and annular size are appropriate for a transcatheter approach.^[3]

TAVI rows for native AR in each guideline

^{[1] [3]}

The two rows cover different patients: the ESC/EACTS 2025 row is for symptomatic patients ineligible for surgery, and the ACC/AHA 2020 row is for surgical candidates with indications for SAVR.^[1][3] ESC/EACTS 2025 says TAVI may be considered at experienced centres for selected patients with AR who are ineligible for surgery.^[1] It says non-dedicated transcatheter valves for this indication are off-label and associated with an increased risk of valve malpositioning and residual AR, with higher rates of second valve implantation (about 10%) or surgical conversion, compared with TAVI in AS.^[1] Dedicated devices appear to minimise the risk of valve migration and residual AR in selected patients, but are associated with a high new permanent pacemaker implantation rate (24%).^[1]

The dedicated-valve data: ALIGN-AR

^{[6] [7]}

Both ALIGN-AR reports are single-arm studies in patients at high surgical risk, judged against prespecified performance goals.^[6][7] TAVI for aortic stenosis is covered in Severe aortic stenosis: TAVI versus surgical valve replacement.

Medical therapy

Start with what vasodilators do not do.^[3] ACC/AHA 2020 says there is no evidence that vasodilating drugs reduce the severity of AR or alter the disease course in patients with significant AR in the absence of systemic hypertension.^[3] Recommendations for guideline-directed medical therapy (GDMT) for hypertension and HF apply to patients with chronic asymptomatic AR, as for the general population.^[3]

ACC/AHA 2020: recommendations for medical therapy of chronic AR (both rows)

^[3]

• Vasodilators (ACC/AHA 2020 text). Vasodilating drugs such as ACE inhibitors or ARBs do not affect heart rate and thus may reduce systolic blood pressure without a substantial reduction in diastolic blood pressure in patients with chronic AR.^[3]
• Not a substitute (ACC/AHA 2020 text). In symptomatic patients who are candidates for surgery, medical therapy is not a substitute for AVR; it is helpful for alleviating symptoms in patients at very high surgical risk because of comorbid conditions.^[3]
• Symptomatic relief (ESC/EACTS 2025 text). Medical therapy, especially ACE inhibitors or dihydropyridine calcium channel blockers, may provide symptomatic improvement in chronic severe AR when surgery is not feasible or is contraindicated.^[1]
• Not to delay surgery (ESC/EACTS 2025 text). The value of ACE inhibitors or dihydropyridines in delaying surgery in moderate or severe AR in asymptomatic patients has not been established, and their use is not recommended for this indication.^[1]
• Beta-blockers (ESC/EACTS 2025 text). They increase the length of diastole and therefore the RVol, and should be used with caution if indicated for another reason; after surgery they can be used with ACE inhibitors or ARBs, if indicated (systolic HF or heart rate control).^[1]

None of the held guideline sections gives drug doses for AR; dosing follows local formulary and specialist guidance.^[3][1]

The aorta in aortic regurgitation

ESC/EACTS 2025 says aortic dilatation is closely linked to AR, and dedicated ESC guidelines give guidance on evaluating and managing aortic root and ascending aortic dilatation.^[1] It says the presence of associated aortic dilatation dictates surgery, irrespective of AR severity.^[1] The aortic phenotype, the degree and rate of progression of dilatation and the underlying aetiology all affect timing of surgery, with the main indication being maximum aortic diameter.^[1] Dilation of the aortic root, which typically occurs in Marfan syndrome and other connective tissue disease, has a worse prognosis than isolated dilatation of the ascending aorta and requires closer surveillance.^[1]

• ESC/EACTS 2025 text. Surgery is recommended in all patients with a maximal aortic root or ascending aneurysm diameter of ≥55 mm.^[1]
• ESC/EACTS 2025 text. In the presence of additional risk factors, a threshold of 50 mm may be considered for selected low-risk patients treated at experienced centres.^[1]
• ESC/EACTS 2025 text. If the patient has an established indication for AV surgery (due to AR or AS), concomitant surgery of the aortic root or the ascending aorta should be considered at a diameter of ≥45 mm.^[1]
• ESC/EACTS 2025 text. This threshold has been more clearly demonstrated in BAV and should also be based on the patient’s height or specific intraoperative findings, such as the shape and thickness of the aortic wall.^[1]
• ESC/EACTS 2025, Class IIa, Level C. When AV surgery is indicated and the predicted surgical risk is low, replacement of the aortic root or ascending aorta should be considered if the maximal diameter is ≥45 mm (considering age, BSA, the aetiology of the valvular disease, the presence of a bicuspid AV, and the intraoperative shape and thickness of the ascending aorta).^[1]

For the full aortic thresholds, the ESC/EACTS 2025 Figure 5 (Management of patients with aortic regurgitation) legend points to the 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases.^[1] Their rows on the aortic root and ascending aorta follow.^[1][4]

ESC 2024 aortic diseases, Recommendation Table 38: surgery in aortic root and ascending aorta dilatation associated with tricuspid aortic valve (selected rows)

^[4]

In that table, resistant hypertension means hypertension that cannot be adequately controlled despite three or more agents recommended by a physician with expertise in hypertension.^[4] Aortic length is the curvilinear distance at the aortic centreline from the ventriculo-aortic junction to the origin of the innominate artery.^[4]

ESC 2024 aortic diseases, Recommendation Table 68: bicuspid aortic valve-associated aortopathy management (all ten rows)

^[4]

ESC 2024 aortic diseases, Recommendation Table 62: aortic surgery in Marfan syndrome (selected rows)

^[4]

Follow-up of the aorta is set out in ESC/EACTS 2025.^[1] When the baseline aortic diameter is >45 mm, it recommends a second TTE at 6 months to confirm stability, followed by serial examinations on a yearly basis.^[1] Any increase of >3 mm should be validated by CT angiography/CMR and compared with baseline data.^[1] After repair of the ascending aorta, patients with Marfan syndrome and other connective tissue diseases remain at risk for dissection of untreated portions of the aorta and require lifelong regular multidisciplinary follow-up at an expert centre.^[1]

ESC/EACTS 2025 also addresses screening of first-degree relatives.^[1] ESC/EACTS 2025 says that, given the familial risk of thoracic aortic aneurysms, screening with appropriate imaging and genetic testing in first-degree relatives is indicated in connective tissue disease.^[1] Since aortic dilation is present in about 10% of first-degree relatives of patients with a BAV, it considers it appropriate to encourage echocardiographic screening in this population.^[1]

^{[4] [1]}

Surveillance

Follow-up intervals depend on AR severity and on how close the LV is to the surgical thresholds.^[1] ESC/EACTS 2025 says a multimodality imaging approach and biomarkers like BNP might help identify patients at increased risk of LV damage early and guide the timing of intervention.^[1]

Follow-up intervals in AR: ESC/EACTS 2025 text and the ACC/AHA 2020 Table 5 aortic regurgitation column

^{[1] [3]}

ACC/AHA 2020 Table 5 is titled Frequency of Echocardiograms in Asymptomatic Patients With VHD and Normal LV Function.^[3] Its notes say the intervals apply to most patients with each valve lesion and do not take into consideration the etiology of the valve disease.^[3] Patients with mixed valve disease may require serial evaluations at intervals earlier than recommended for single-valve lesions.^[3] When there is an apparent significant fall in EF or increase in LV size, the ACC/AHA 2020 supportive text says repeat imaging typically is performed at 3- to 6-month intervals unless there is clinical deterioration.^[3]

^{[3] [1]}

Prognosis

• Symptoms (ACC/AHA 2020). Patients with chronic severe AR who develop symptoms have a high risk of death if AVR is not performed.^[3]
• LV measures (ACC/AHA 2020). LVEF or fractional shortening, and LVESD or LV end-systolic volume, predict the development of HF symptoms or death in initially asymptomatic patients (Stages B and C1).^[3]
• After surgery (ACC/AHA 2020). Symptomatic patients (Stage D) with normal LVEF have a significantly better long-term postoperative survival rate than those with depressed systolic function.^[3]
• The root (ESC/EACTS 2025). Dilation of the aortic root has a worse prognosis than isolated dilatation of the ascending aorta.^[1]
• Moderate AR (ESC/EACTS 2025). Data show that progression of moderate AR may be very slow.^[1]

Special populations and scenarios

Pregnancy

ESC 2025 (pregnancy) says valve regurgitation is generally better tolerated than valve stenosis in pregnancy, although increased maternal and foetal event rates can be seen with severe regurgitation.^[5] Women with valve regurgitation and either symptoms or LV dysfunction incur an increased risk of HF, occurring in 20%–25% of those with at least moderate regurgitation.^[5] It says diuretics can be used in severe symptomatic mitral or aortic regurgitation, cardiac surgery is rarely required during pregnancy, and vaginal delivery is preferred unless the mother is in refractory HF.^[5]

ESC 2025 pregnancy, Recommendation Table 18: native valve disease and pregnancy (selected rows)

^[5]

ESC/EACTS 2025 (valve guideline) adds that valvular regurgitant lesions are generally well tolerated during pregnancy, and that prophylactic intervention is therefore not recommended in the absence of class I or IIa indications.^[1] In its paragraph on valve choice in a woman considering pregnancy, it says the Ross procedure may be considered for the treatment of AV disease at centres with expertise.^[1]

ESC 2025 pregnancy, Recommendation Table 8: aortopathies, cardiac surgery and pregnancy, group heading "Specific conditions" (selected rows)

^[5]

These Table 8 rows are written for women before pregnancy, and the topic gives them alongside the ESC 2024 Marfan and bicuspid aortopathy rows above.^[5][4]

Women

ESC/EACTS 2025 says indexed cut-offs to indicate treatment of AR are validated, but only partially account for sex differences.^[1] Newer studies using echocardiographic volumes and CMR suggest that women may experience higher event rates at lower cut-offs than men, but this requires further investigation.^[1] ACC/AHA 2020 says indexing LVESD for body size is important, particularly in women or small patients.^[3]

AR at other cardiac surgery

Severe AR found at other cardiac surgery is covered by rows in both guidelines.^[1][3] ESC/EACTS 2025 Recommendation Table 3 recommends AV surgery in symptomatic and asymptomatic patients with severe AR undergoing CABG or surgery of the ascending aorta (Class I, Level C).^[1] Its Recommendation Table 11 (concomitant left-sided valvular heart disease), under the heading Concomitant aortic regurgitation, recommends AV surgery in patients with severe AR undergoing surgery for another valve (Class I, Level C).^[1] ACC/AHA 2020 says that in patients with severe AR (Stage C or D) undergoing cardiac surgery for other indications, aortic valve surgery is indicated (COR 1, LOE C-EO).^[3]

ACC/AHA 2020 says that in patients with moderate AR (Stage B) undergoing cardiac or aortic surgery for other indications, aortic valve surgery is reasonable (COR 2a, LOE C-EO).^[3] Its supportive text says the decision includes aortic valve anatomy, aortic root size and shape, regurgitant severity, other comorbidities, and patients’ preferences and values.^[3] ESC/EACTS 2025 says that in moderate AR with an indication for CABG or MV surgery, the Heart Team should discuss whether to treat the AV.^[1] It bases the decision on the aetiology of AR and other factors such as estimated life expectancy and operative risk, as data show that progression of moderate AR may be very slow.^[1]

Mixed moderate AS and moderate AR

ESC/EACTS 2025 says transvalvular gradients measured by Doppler reflect the overall haemodynamic burden of both regurgitation and stenosis, and are strongly associated with adverse outcomes.^[1] High gradients justify intervention in moderate mixed AV disease even if regurgitation is graded as moderate and the calculated or planimetric AVA is >1 cm².^[1]

ESC/EACTS 2025 Recommendation Table 12: mixed moderate aortic stenosis and moderate aortic regurgitation (both rows)

^[1]

Atrial fibrillation

ESC/EACTS 2025 Recommendation Table 2 (atrial fibrillation in native valvular heart disease), under the heading Anticoagulation, recommends DOACs for stroke prevention in preference to VKAs in patients with AF and AS, AR or MR who are eligible for OAC (Class I, Level A).^[1]

Non-cardiac surgery

ESC/EACTS 2025 says non-cardiac surgery (NCS) can usually be performed safely in asymptomatic patients with severe AR and preserved LV function.^[1] If NCS is urgent, patients should undergo surgery under strict haemodynamic monitoring, regardless of symptom status.^[1] Valve treatment should be performed for patients with AR meeting the criteria for valve intervention before any elective intermediate- or high-risk NCS.^[1]

The 2022 ESC non-cardiac surgery guideline gives the formal row, in its Recommendation Table 21 under the heading Aortic valve regurgitation.^[10] In patients with symptomatic severe AR, or asymptomatic severe AR and LVESD >50 mm or LVESDi >25 mm/m² (in patients with small body size) or resting LVEF ≤50%, it recommends valve surgery prior to elective intermediate- or high-risk NCS (Class I, Level C).^[10]

Sport and physical activity

ESC/EACTS 2025 says aortic dilation with AR in asymptomatic patients raises the question of limiting physical activity, but consistent data are lacking.^[1] Current recommendations for competitive sport are restrictive, especially for isometric exercise in connective tissue disease, while a more liberal approach is likely to be appropriate in other patients.^[1]

Prohibitive surgical risk

ACC/AHA 2020 recommends GDMT for reduced LVEF with ACE inhibitors, ARBs and/or sacubitril/valsartan in severe AR with symptoms and/or LV systolic dysfunction (Stages C2 and D) but a prohibitive surgical risk (COR 1, LOE B-NR).^[3] ESC/EACTS 2025 says TAVI may be considered for severe AR in symptomatic patients ineligible for surgery according to the Heart Team, if the anatomy is suitable (Class IIb, Level B).^[1]

Evidence, guidelines and regional differences

• LVEF threshold. In asymptomatic severe AR, ESC/EACTS 2025 recommends AV surgery at a resting LVEF ≤50% (Class I, Level B) and says it may be considered at a resting LVEF ≤55% if the surgical risk is low (Class IIb, Level B). ACC/AHA 2020 indicates it in asymptomatic chronic severe AR at LVEF ≤55% (Stage C2) if no other cause for systolic dysfunction is identified (COR 1, LOE B-NR).^[1][3]
• Indexed LVESD. In asymptomatic severe AR, ESC/EACTS 2025 puts LVESDi >25 mm/m² [especially in patients with small body size (BSA <1.68 m²)] in its Class I, Level B row, and LVESDi >22 mm/m² in its Class IIb, Level B row if the surgical risk is low. ACC/AHA 2020 puts LVESD >50 mm or indexed LVESD >25 mm/m² with LVEF >55% in asymptomatic severe AR (Stage C2) in a COR 2a, LOE B-NR row.^[1][3]
• Earlier thresholds. In asymptomatic severe AR, ESC/EACTS 2025 gives LVESDi >22 mm/m², LVESVi >45 mL/m² (using echocardiography or CMR) [especially in patients with small body size (BSA <1.68 m²)] or resting LVEF ≤55% a Class IIb, Level B row if the surgical risk is low. ACC/AHA 2020 gives a COR 2b, LOE B-NR row to asymptomatic patients with LVEF >55% at rest (Stage C1) and low surgical risk. That row needs a progressive decline in LVEF on at least 3 serial studies to the low–normal range (LVEF 55% to 60%) or a progressive increase in LV dilation into the severe range (LVEDD >65 mm).^[1][3]
• TAVI. ESC/EACTS 2025 says TAVI may be considered in symptomatic patients ineligible for surgery according to the Heart Team, if the anatomy is suitable (Class IIb, Level B); ACC/AHA 2020 says TAVI should not be performed in isolated severe AR in surgical candidates with indications for SAVR (COR 3: Harm, LOE B-NR).^[1][3]
• Evidence gaps. ACC/AHA 2020 says more outcome data, and ideally an RCT, of earlier intervention are needed. ESC/EACTS 2025 says reduced longitudinal strain and contractile reserve at stress echocardiography, elevated BNP and myocardial fibrosis on CMR need to be integrated in decision-making, even if not entirely validated yet.^[3][1]
• Newer trial data. The 2024 and 2025 ALIGN-AR reports are single-arm studies of a dedicated valve in high-surgical-risk symptomatic patients with moderate-to-severe or severe AR.^[6][7]

ANZ practice: the 2024 CSANZ Position Statement on transthoracic echocardiography (TTE) in structural and valvular heart disease aims to give clinicians a framework of acceptable indications for initial and serial TTE, and imaging providers the minimum standard for TTE examinations and reporting.^[8] Only its abstract is used for this topic, so its AR intervals are not quoted. The 2021 CSANZ and ANZSCTS TAVI statement sets the minimum standard for accrediting institutions and operators and says it is not a guideline statement.^[9] No NHFA/CSANZ guideline on aortic regurgitation was found among the guidelines checked for this topic, so the ESC/EACTS and ACC/AHA rows above apply. Guidelines used for this topic: 2025 ESC/EACTS valvular heart disease; 2020 ACC/AHA valvular heart disease; 2024 ESC peripheral arterial and aortic diseases; 2025 ESC cardiovascular disease and pregnancy; 2022 ESC non-cardiac surgery; and the CSANZ statements above. Also checked was a PubMed census of AR guidance and trials to October 2026. For each source guideline, every held guideline published in the same month or later was swept for recommendations on AR, the aortic root or ascending aorta, bicuspid aortopathy, Marfan syndrome or aortic valve intervention; the sweep included the 2025 AHA/ACC high blood pressure guideline. The 2025 ACC/AHA adult congenital heart disease guideline and the 2026 AHA/ACC perioperative guideline for noncardiac surgery are not held as text for this topic and are not used. US aortic diameter thresholds are not given here: the 2022 ACC/AHA aortic disease guideline is held but not used as a source for this topic, and nor are the ACC/AHA 2020 rows on replacing the aorta in patients with a BAV (Section 5.1.2.1).^[3]

Complications and pitfalls

Exam pearls

^{[1] [3]}

References10ShowHide

1. [1]Praz F, et al. 2025 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J, 2025.PMID 40878295
2. [2]Otto CM, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2021.PMID 33332150
3. [3]Otto CM, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2021.PMID 33342586
4. [4]Mazzolai L, et al. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J, 2024.PMID 39210722
5. [5]De Backer J, et al. 2025 ESC Guidelines for the management of cardiovascular disease and pregnancy. Eur Heart J, 2025.PMID 40878294
6. [6]Vahl TP, et al. Transcatheter aortic valve implantation in patients with high-risk symptomatic native aortic regurgitation (ALIGN-AR): a prospective, multicentre, single-arm study. Lancet, 2024.PMID 38552656
7. [7]Makkar RR, et al. Transcatheter aortic valve implantation with the Trilogy valve for symptomatic native aortic regurgitation (ALIGN-AR): a pivotal, multicentre, single-arm, investigational device exemption study. Lancet, 2025.PMID 41260228
8. [8]Chong A, et al. 2024 CSANZ Position Statement on Indications, Assessment and Monitoring of Structural and Valvular Heart Disease With Transthoracic Echocardiography in Adults. Heart Lung Circ, 2024.PMID 38749800
9. [9]Bennetts J, et al. 2021 CSANZ and ANZSCTS Position Statement on the Operator and Institutional Requirements for a Transcatheter Aortic Valve Implantation (TAVI) Program in Australia. Heart Lung Circ, 2021.PMID 34483050
10. [10]Halvorsen S, et al. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J, 2022.PMID 36017553