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Answer 4
  1. Cardiology consultation for coronary angiography and referral for aortic valve replacement with or without aortic graft.
    In contrast to stenotic aortic valve disease, surgery is indicated for chronic regurgitant aortic valve disease prior to the development of symptoms. The indications for aortic valve replacement with asymptomatic chronic severe aortic insufficiency include new LV systolic dysfunction (defined by the ACC/AHA valve disease guidelines as LVEF ≤ 50%) or severe LV dilatation (LV enddiastolic dimension > 75 mm or LV end- systolic dimension > 55 mm).3 This patient has demonstrated an interval decrease in LV systolic function into the abnormal range of 50% or less, which is a class 1 indication for aortic valve replacement, regardless of LV dimensions.3 As with other valve lesions, patients at risk should be assessed for coronary disease prior to valve surgery. In this case, the patient is also at risk for both aortic dissection and rupture given the presence of a bicuspid aortic valve and a dilated aortic root; therefore, he should also be considered for aortic root replacement with a valved conduit for maximal likelihood of surgical success and recovery of LV systolic function.
    An increase in pulse pressure (the difference between systolic and diastolic blood pressure) with an increased systolic blood pressure is a hallmark of chronic aortic insufficiency due to increased LV preload and may not be controlled on multiple medications. Therefore, medical therapy with a diuretic or β-blocker is not indicated, and in fact, rate-slowing with β-blockade poses theoretical harm because it would prolong diastole, exacerbating the time of insufficiency. Medical therapy with vasodilators such as an ACE inhibitors can be considered but should not delay or be considered a replacement for surgery in patients with chronic severe aortic insufficiency that has already met surgical criteria.

    3. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). J Am Coll Cardiol 2008;52(13):el–142.

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