A 52-year-old man from Delhi presents with progressive dyspnea on exertion for 6 months and orthopnea. On examination, he has an early diastolic decrescendo murmur at the left sternal border, a wide pulse pressure (systolic 160 mmHg, diastolic 50 mmHg), and a collapsing pulse. Chest X-ray shows cardiomegaly and pulmonary edema. Transthoracic echocardiography confirms severe aortic regurgitation with an ejection fraction of 45%. He is currently on amlodipine 5 mg daily. What is the most appropriate next step in management?

Explanation

## Clinical Assessment **Key Point:** Severe aortic regurgitation with symptomatic left ventricular dysfunction (EF 45%, dyspnea, orthopnea) is a Class I indication for aortic valve replacement surgery. ### Pathophysiology of Severe AR 1. Chronic volume overload → eccentric LV hypertrophy 2. Progressive dilatation and systolic dysfunction 3. Once symptomatic or EF <50%, irreversible myocardial damage accelerates ### Indications for AVR in AR [cite:Harrison 21e Ch 297] | Scenario | Indication | Timing | |----------|-----------|--------| | Symptomatic severe AR (any EF) | Class I | Urgent | | Asymptomatic severe AR + EF ≤50% | Class I | Elective | | Asymptomatic severe AR + EF >50% + LV dilatation (LVEDD >70 mm) | Class IIa | Consider | | Asymptomatic severe AR + EF >50% + normal LV size | Class IIb | Serial echo | **High-Yield:** This patient meets TWO criteria for urgent AVR: - Symptomatic (dyspnea, orthopnea) - Reduced EF (45%) ### Why Medical Management Alone Is Insufficient **Clinical Pearl:** Vasodilators (ACE inhibitors, calcium channel blockers) slow but do NOT halt progression in symptomatic severe AR with LV dysfunction. They are bridge therapy only, not definitive treatment. **Warning:** Delaying surgery in symptomatic AR with EF <50% risks: - Further myocardial fibrosis and irreversible dysfunction - Sudden decompensation - Worse post-operative outcomes ### Surgical vs. Medical Pathway ```mermaid flowchart TD A["Severe AR on echo"]:::outcome --> B{"Symptomatic?"}:::decision B -->|"Yes"| C{"EF assessment"}:::decision B -->|"No"| D{"EF ≤50% OR LVEDD >70?"}:::decision C -->|"Any EF"| E["AVR Class I"]:::action D -->|"Yes"| F["AVR Class I"]:::action D -->|"No"| G["Serial echo q6-12 mo"]:::action E --> H["Refer cardiothoracic surgery"]:::action F --> H ``` **Tip:** In NEET PG, symptomatic AR with reduced EF is a straightforward surgical indication—do not be tempted by medical optimization as the "next step."