Sex-Specific Risk Stratification in Aortic Regurgitation: Moving Beyond One-Size-Fits-All Thresholds

Introduction and Context

Aortic Regurgitation (AR) remains a significant challenge in valvular heart disease, characterized by the backflow of blood from the aorta into the left ventricle (LV). This volume overload triggers a compensatory process known as LV remodeling, where the heart chamber dilates and thickens to maintain stroke volume. However, this compensation eventually reaches a tipping point, leading to irreversible myocardial damage, heart failure, and death. For decades, the timing of surgical intervention—specifically Aortic Valve Surgery (AVS)—has been guided by specific thresholds of LV dilatation and ejection fraction.

Currently, both the American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC) provide guidelines for intervention in asymptomatic patients with severe AR. These guidelines rely heavily on the Left Ventricular End-Systolic Diameter Index (LVESDi). While these recommendations aim to standardize care, they have historically applied uniform thresholds regardless of a patient’s sex. Emerging evidence suggests that this ‘one-size-fits-all’ approach may lead to delayed interventions, particularly in women, who generally have smaller baseline cardiac dimensions. A landmark study recently published in *JAMA Cardiology* (Lopez Santi et al., 2026) highlights the urgent need to refine these thresholds to account for sex-specific physiological differences and the superiority of volumetric measurements.