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Answer 5
  1. Repeat clinical assessment in 6 to 12 months with repeat transthoracic echocardiogram in 1 year, or sooner if symptoms develop. This patient has asymptomatic moderate aortic insufficiency without evidence of LV dysfunction or dilatation; one could generally expect a long period without symptoms or development of LV dysfunction and an average mortality rate of less than 0.2% per year.3,4 Therefore, the risks of aortic valve replacement and postoperative complications outweigh its benefits, and valve surgery is not yet indicated.3 However, given the progressive nature of the disease, these patients should be followed closely, ideally with a multidisciplinary team including primary care physicians, cardiologists, and cardiothoracic surgeons. Although most patients with chronic aortic insufficiency develop symptoms prior to development of LV dysfunction, more than one quarter who die or develop systolic dysfunction do so before the onset of warning symptoms. Therefore, noninvasive assessment, generally with transthoracic echocardiography, is indicated, with particular attention to LV dimensions and LV systolic function.3 Moreover, if the transthoracic echocardiography is of good quality, which is the case in this patient, there is no indication for invasive aortography.
    The 2008 AHA focused update on infectious endocarditis suggests that antibiotic prophylaxis is only recommended for patients with a high risk of endocarditis defined as (1) patients with prosthetic heart valves, (2) patients with complex congenital heart disease, (3) patients with valvulopathy in a transplanted heart, and (4) patients with a prior history of endocarditis.4 The presence of aortic insufficiency alone, as seen in this patient, is no longer a recommendation for antibiotic prophylaxis.4

    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. 4. Nishimura RA, Carabello BA, Faxon DP, et al. ACC/AHA 2008 Guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008;52:676–85.

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