Aortic regurgitation today is the third most common valvular pathology in industrial countries, either isolated to the valve or in conjunction with aortic disease. With changing demographics it can be expected to increase in prevalence in the next years. The past years have brought about dynamic changes in surgical options, imaging techniques and also patient expectations. A group of internationally highly renowned authors from different specialties have made a joint effort to provide a state-of-the-art overview of all aspects of the disease. Anatomy, pathology, cardiological aspects and current guidelines are presented by leaders in their fields. Surgical techniques and their long-term results are summarised by an international team of individuals with a strong track record in their respective areas. The topics are presented precisely, comprehensively and can be a reference to all health care professionals seeking information on the latest developments.

1. Anatomy (Basso C, Lansac E, Rizzo S, Thiene G) 15 1.1. The pathology of aortic incompetence 15 1.1.1. Introduction and historical notes 15 1.1.2. Aortic root anatomy 15 1.1.3. Embryology of the aortic valve 17 1.1.4. The aorta 18 1.1.5. The pathology of the aortic root and aortic incompetence 18 1.1.6. Inflammatory disease of the aortic valve 18 1.1.6.1. Rheumatic valve disease 18 1.1.6.2. Infective endocarditis 20 1.1.6.3. Degenerative pathology of the aortic root 20 1.1.6.4. Aortic dissection 22 1.1.6.5. Rare causes of native aortic valve incompetence 23 1.1.6.6. Aetiology of aortic regurgitation in surgical pathology experience 23 1.1.6.7. Regurgitation in prosthetic aortic valves 23 1.2. Functional anatomy of the aortic valve and dynamics of aortic root 27 1.2.1. Echocardiographic anatomy of the normal aortic root 28 2. Aortic regurgitation – Epidemiology, natural history, guidelines (Iung B, Vahanian A) 32 2.1. Epidemiology and aetiologies 32 2.1.1. Degenerative aortic regurgitation 32 2.1.2. Bicuspid aortic valve disease 33 2.1.3. Rheumatic heart disease 33 2.1.4. Infective endocarditis 34 2.1.5. Inflammatory aortic diseases 34 2.1.6. Aortic dissection 34 2.1.7. Other causes of aortic regurgitation 34 2.2. Natural history 34 2.2.1. Severity of aortic regurgitation 34 2.2.2. Consequences of aortic regurgitation on the left ventricle 34 2.2.3. Enlargement of ascending aorta 35 2.3. Current guidelines 35 2.3.1. Diagnostic workup 37 2.3.2. Indications for the correction of aortic regugitation 37 2.3.3. Indications for surgery of the ascending aorta 38 2.3.4. Medical therapy 38 3. Aortic regurgitation: Role of echocardiography (Vanoverschelde J-L) 42 3.1. Echocardiographic examination of the aortic valve and root 42 3.2. Echocardiographic assessment of aortic regurgitation severity 43 3.2.1. Colour flow Doppler 43 3.2.2. Vena contracta width 44 3.2.3. The flow convergence method 44 3.2.4. Pulsed Doppler volumetric method 45 3.2.5. Diastolic flow reversal in the descending aorta 45 3.2.6. Continuous-wave Doppler of the aortic regurgitation jet 46 3.3. Echocardiographic assessment of the haemodynamic consequences of aortic regurgitation 46 3.4. Echocardiographic assessment of the mechanisms of aortic regurgitation and prediction of reparability 46 3.4.1. Functional anatomy of aortic regurgitation 46 3.4.2. Assessment of aortic valve reparability 48 3.5. Echocardiographic assessment of the results of aortic regurgitation repair 49 4. Aortic regurgitation: Medical treatment (Vanoverschelde J-L) 51 5. Mechanical valve/composite replacement for aortic regurgitation or aneurysm (Ikonomidis JS, Theruvath TP) 53 5.1. History of mechanical heart valves 53 5.2. Aortic regurgitation and aneurysm 54 5.3. Surgical technique 54 5.4. Results of mechanical valve graft replacements 57 6. Aortic regurgitation with and without aneurysmal disease (Deb S, Fremes SE, Tsubota H) 63 6.1. History and Background of Biological Valves 63 6.2. Mechanical versus Bioprosthetic Valve Studies 63 6.3. Stented vs Stentless Bioprosthetic Valves 64 6.4. Technique of the Stented Bioprosthetic Aortic Valve Replacement 65 6.5. Results of aortic valve replacement 67 6.6. Aneurysmal Ascending Aorta and Aortic Regurgitation 67 6.7. Composite Valve-Graft Technique 68 6.8. Results of Composite aortic valve replacement 70 7. Ross operation (Stelzer P, Varghese R) 74 7.1. Indications in aortic regurgitation 74 7.2. Technique for Ross root replacement in treatment of aortic regurgitation 75 7.3. Addressing a concomitantly dilated ascending aorta 76 7.4. Results 77 8. Valve repair (Aicher D, Schäfers, H-J) 80 8.1. Background 80 8.2. Normal aortic valve anatomy 80 8.3. Differential indication, i.e., when to choose repair 81 8.4. Surgical techniques 82 8.4.1. Exposure and valve assessment 82 8.4.2. Correction of prolapse 83 8.4.3. Design alteration 86 8.4.4. Annuloplasty 88 8.5. Results 88 9. Valve preserving aortic replacement (Kunihara T, Schäfers H-J) 93 9.1. Definition of valve-preserving surgery 93 9.2. Indications for valve-preserving surgery 93 9.3. Surgical techniques 94 9.3.1. Root remodelling 94 9.3.2. Valve reimplantation 95 9.3.3. Aortic valve assessment and correction 96 9.4. Results 97 10. The aorto-ventricular junction in aortic repair (Di Centa I, Lansac E) 102 10.1. Anatomical rationale for aortic annuloplasty 102 10.2. Aortic annuloplasty techniques and devices 102 10.2.1. Suture annuloplasty 102 10.2.2. Aortic rings 103 11. Computer simulation of aortic valve geometry (Haj-Ali R, Marom G, Raanani E, Rosenfeld M, Schäfers H-J) 110 11.1. Background 110 11.2. Methods 110 11.3. Effect of aortoventricular junction on cusp configuration and stress 110 11.4. Effect of geometric height on cusp configuration and stress 111 11.5. Clinical implications 111 12. Long-term results of aortic valve surgery (Mokhles MM, Takkenberg JJM) 114 12.1. Mechanical valve replacement 115 12.2. Biologic valve replacement 116 12.3. Autograft valve replacement 117 12.4. Repair/valve-preserving aortic surgery 119 12.5. Selecting the preferred surgical strategy 120 Index 126