Aortic Regurgitation | Dr. Julius Kwedhi | Auxanö Medical Podcast

In this episode, Dr. Julius Kwedhi breaks down everything you need to know about aortic regurgitation — one of cardiovascular surgery's most nuanced conditions. Whether you are a fellow preparing for boards, a consultant refreshing your practice, or a surgeon building a cardiac programme in a resource-limited setting, this episode covers the full clinical and surgical spectrum.

What we cover:

We open with the remarkable history of AR — from Dominic Corrigan's 1832 description in syphilitic aortitis to the rich legacy of eponymous signs that still define the bedside examination today. The water-hammer pulse, De Musset's head bob, Quincke's nail-bed pulsations, Duroziez's to-and-fro femoral murmur, the Austin Flint rumble — each sign is explained with its physiological mechanism and real clinical utility. We then move through pathophysiology: why the volume-overloaded ventricle tolerates AR for decades but eventually reaches a point of no return, and why that irreversible myocardial fibrosis — not the valve itself — is what ultimately kills these patients if surgery is delayed too long.

We discuss the 2025 ESC/EACTS guidelines in detail, including the most clinically important changes: the new Class IIa thresholds for earlier surgery in asymptomatic patients (LVESDi >22 mm/m², LVESVi >45 mL/m², LVEF ≤55% in low-risk patients), the divergence with the 2021 ACC/AHA guidelines on the LVEF threshold for Class I surgery (50% vs 55%), and — the biggest news — the first-ever guideline recognition of transcatheter therapy for native AR, awarded Class IIb on the back of the ALIGN-AR trial.

The ALIGN-AR trial is covered in full: 500 patients, 28 US centres, the JenaValve Trilogy's leaflet-grasping anchor mechanism, 96.4% device success, 1.4% thirty-day mortality, zero cases of moderate or greater paravalvular regurgitation at one year, and the FDA approval that followed in March 2026 — a genuine paradigm shift for inoperable patients.

On the surgical side, we go deep on the Ross procedure — why the 25-year CARNET registry data and the 24-year Harefield RCT follow-up both show general-population-equivalent survival, and why a network meta-analysis now confirms the Ross outperforms both mechanical and bioprosthetic valves for mortality in young adults. We discuss external autograft reinforcement as the technical advance that may resolve late autograft dilation. We cover the David reimplantation versus Yacoub remodelling debate, including the 2024 meta-analysis demonstrating superior survival and freedom from reoperation with reimplantation.

A dedicated segment addresses the sub-Saharan African context: rheumatic AR presenting at age 15 to 45, the REMEDY registry data, the anticoagulation dilemma for mechanical valves in settings with unreliable INR monitoring, why the Ross procedure is the optimal solution for young LMIC patients, and the practical role of benzathine penicillin G prophylaxis in preventing recurrent valvular damage.

We close with the drugs: the 24-agent pharmacology table explained — ACE inhibitors, ARBs, dihydropyridines, loop diuretics, MRAs, SGLT2 inhibitors including the DapaTAVI results — and the absolute contraindications in acute severe AR that every surgeon and intensivist must know: no IABP, no beta-blockers, and no delay.

Key references discussed: 2025 ESC/EACTS Guidelines (EHJ 2025;46:4635); ALIGN-AR (Lancet 2025;406:2757); CARNET Ross Registry (JACC 2021;77:1412); Harefield post-hoc RCT (JAMA Cardiol 2024;9:6); El-Hamamsy propensity-matched series (JACC 2022;79:805); David 20-year series (JTCVS 2021;161:890); REMEDY Registry (EHJ 2015;36:1115).

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