Recommendations for aortic valve replacement (AVR) in asymptomatic patients with severe aortic regurgitation (AR) embedded in international practice guidelines have traditionally cited thresholds for surgical referral based on left ventricular (LV) ejection fraction (EF) and LV linear dimension (end-systolic diameter index, LVESDi). A modest (Class 2b) recommendation for surgical referral based on assessment of LV end-systolic volume index (LVESVi) appears for the first time in the 2025 European guideline. The evidence base for these sex-agnostic recommendations has been derived from male-dominated observational studies that have relied primarily on echocardiography, with more recent use of cardiac magnetic resonance. Importantly, inadequate attention has been paid to the significant differences in the LV response to chronic volume overload, timing of referral, and long-term outcomes between women and men with severe AR.
Recommendations for aortic valve replacement (AVR) in asymptomatic patients with severe aortic regurgitation (AR) embedded in international practice guidelines have traditionally cited thresholds for surgical referral based on left ventricular (LV) ejection fraction (EF) and LV linear dimension (end-systolic diameter index, LVESDi). A modest (Class 2b) recommendation for surgical referral based on assessment of LV end-systolic volume index (LVESVi) appears for the first time in the 2025 European guideline. The evidence base for these sex-agnostic recommendations has been derived from male-dominated observational studies that have relied primarily on echocardiography, with more recent use of cardiac magnetic resonance. Importantly, inadequate attention has been paid to the significant differences in the LV response to chronic volume overload, timing of referral, and long-term outcomes between women and men with severe AR.