ESC / EACTS · 2025

Aortic Regurgitation — Management Guideline

Source: 2025 ESC/EACTS Guidelines for the management of valvular heart disease, European Heart Journal

✓ Edition checked 3 Oct 2026 — ESC / EACTS 2025 is the current edition as of this date.

Guideline: Strong Guideline: Conditional Guideline: Not recommended ClinicoQ pathway suggestion (not from the cited guideline)

Diagnosis

Diagnostic criteria Severity is assessed by integrating echocardiographic quantification with the effect on the left ventricle (LVEF, end-systolic diameter and its indexed value, and volumes), with CMR used when echocardiography is inconclusive. Decisions rest on symptoms, LV dimensions and function, associated aortic dilatation, and surgical risk, in a Heart Team setting.

⚠ Alarm features (investigate before diagnosing)

New or worsening dyspnoea or angina
Fall in LVEF to 50% or below, or progressive LV dilatation
Aortic root or ascending aorta diameter approaching 55 mm
Acute severe aortic regurgitation (endocarditis, dissection, trauma)

Initial workup

Test	When to order
Transthoracic echocardiography	Severity and mechanism, LVEF, LVESD and indexed LVESD, LV end-systolic volume index, and aortic root and ascending aorta dimensions at diagnosis and during surveillance.
Multimodality imaging including CMR and CT	When echocardiography is inconclusive, to quantify regurgitation and LV volumes (CMR) and to measure the aorta (CT or CMR); the EACVI/ESC position paper recommends a multimodality approach.
Heart Team assessment	Before any intervention, to choose between surgery, repair, and transcatheter options.

Decision Points

❓ What is the clinical picture?

Symptomatic severe aortic regurgitation → Symptomatic severe aortic regurgitation

Asymptomatic severe aortic regurgitation → Asymptomatic severe aortic regurgitation

Associated aortic root or ascending aorta dilatation → Aortic root or ascending aorta dilatation

Treatment

Symptomatic severe aortic regurgitation

1 Aortic valve surgery Strong (Guideline recommendation) — Class I, level B unless the anticipated surgical risk is prohibitive

Dose: —
Duration: Timely, once symptomatic severe regurgitation is confirmed
Evidence level: High
Avoid if: Prohibitive surgical risk
If no response: If surgery is not possible, consider TAVI in suitable anatomy

2 Aortic valve repair in selected patients Guideline recommendation (Class IIa, level B) — should be considered when a durable result is expected; valve-sparing root replacement is recommended in young patients with root dilatation at experienced centres

Dose: —
Duration: Elective, at an experienced centre
Evidence level: Moderate
Avoid if: Unsuitable valve morphology or lack of an experienced repair team

3 TAVI in patients ineligible for surgery Guideline recommendation (Class IIb, level B) — may be considered for symptomatic severe regurgitation when the Heart Team judges the patient ineligible for surgery and the anatomy is suitable

Dose: —
Duration: Procedure
Evidence level: Low
Avoid if: Unsuitable anatomy

Asymptomatic severe aortic regurgitation

1 Aortic valve surgery for LV dysfunction or dilatation Strong (Guideline recommendation) — Class I, level B (traditional thresholds reaffirmed)

Dose: Triggers: LVEF 50% or below, or LVESD above 50 mm, or indexed LVESD above 25 mm/m2 (especially with small body size, BSA below 1.68 m2)
Duration: Elective
Evidence level: High
Avoid if: Prohibitive surgical risk

2 Aortic valve surgery for earlier LV changes at low surgical risk Guideline recommendation (Class IIb, level C) — may be considered only if surgery is low risk

Dose: Triggers: LVEF 55% or below, or indexed LVESD above 22 mm/m2, or indexed LV end-systolic volume above 45 mL/m2
Duration: Elective
Evidence level: Low
Avoid if: Moderate or high surgical risk
If no response: Continue surveillance if surgery is not chosen

3 Concomitant aortic valve surgery when another cardiac operation is needed Strong (Guideline recommendation) — Class I, level C in patients needing CABG, ascending aorta surgery, or another cardiac surgical procedure

Dose: —
Duration: At the time of the other operation
Evidence level: Moderate
Avoid if: —

Aortic root or ascending aorta dilatation

1 Surgery for aortic root or ascending aortic aneurysm Strong (Guideline recommendation) — recommended in all patients, irrespective of the severity of regurgitation

Dose: Maximal diameter 55 mm or above
Duration: Elective
Evidence level: High
Avoid if: —
If no response: A lower threshold of 50 mm may be considered in selected low-risk patients with additional risk factors

2 Lower diameter threshold in selected low-risk patients Guideline recommendation (may be considered) — selected low-risk patients treated at experienced centres

Dose: Maximal diameter 50 mm with additional risk factors
Duration: Elective, at an experienced centre
Evidence level: Low
Avoid if: High surgical risk or lack of an experienced centre

3 Concomitant root or ascending aorta surgery during aortic valve surgery Guideline recommendation (should be considered) — when aortic valve surgery is already indicated for regurgitation or stenosis

Dose: Diameter 45 mm or above
Duration: At the time of valve surgery
Evidence level: Moderate
Avoid if: —

⚠️ This is an educational summary of current international clinical practice guidelines and does not replace individualized clinical judgment. Final treatment decisions remain the responsibility of the treating physician.