Aortic Valve Regurgitation (AR)

by | Aug 1, 2015 | Cardiology |

Aortic Regurgitation (AR)

Acute Aortic Regurgitation

Acute AR Symptoms:

  • Acute tachycardia
  • Acute dyspnea

Acute AR Signs:

  • Tachycardia
  • Severe HF Sx: rales, edema
  • Soft S1
  • Hypotension
  • Diastolic murmur may be short or inaudible
  • S3/S4

Acute Severe AR Treatment:

  • Urgent surgical replacement (AVR) or repair
  • Nitroprusside IV, Inotropes
  • DO NOT use Intra-Aortic Balloon Pump (IABP)
  • DO NOT use beta blockers or pressors

 

 

Chronic Aortic Regurgitation

Chronic AR Symptoms:

  • Prolonged asymptomatic stage, then dyspnea

Chronic AR Signs:

  • Loud decrescendo diastolic murmur at R upper sternal border (holodiastolic)
  • +/- Austin Flint murmur
  • Wide pulse pressure
  • Bisferiens pulse
  • Head nodding, capillary pulsations, pistol-shot femoral pulses, pulsatile uvula

Chronic AR Etiology:

  • Intrinsic valvular:  degenerative, calcification, bicuspid, rheumatic, connective tissue Dz, IE, myxomatous, anorectic drugs
  • Ascending aorta:  degenerative, dissection, Marfan’s, Ehlers-Danlos, inflammatory/aortitis, giant cell arteritis
  • A disease of LV volume and pressure overload
  • Increased preload,  Increased afterload –> often large LV (cor bovinatum)
  • EF is relatively unchanged with corrective surgery

Echocardiography in Chronic AR:

  • Signs of severe AR:  PHT < 200 msec, regurg vol > 60 mL,  regurg fraction > 55%, color jet > 60% LVOT
  • Premature MV closure
  • Flow reversal in the proximal descending thoracic aorta

Treadmill in Chronic AR:  can do treadmill for estimation of exercise capacity, no need for LVEF changes

Catheterization in Chronic AR:

  • Do a cath if echo and Sx are discrepant
  • LV pressure tracing shows gradual rise in diastole
  • Wide pulse pressure
  • Effacement of the dicrotic notch

MRI

  • If echo cannot diagnose AR severity, cardiac MRI (CMR) is the next modality

Surgical Indications for Severe Chronic AR:

  • Severe AR + any symptoms
  • Severe AR + LVEF < 50%
  • Severe AR + ESD > 50 mm
  • Moderate AR + other cardiac surgical indications

Medical Adjunctive Therapy for Chronic AR:

  • No prophylactic need for vasodilators.  Use vasodilators if asymptomatic, hypertensive, and poor surgical candidate
  • Treat HTN with CCB or ACEI
  • ACEI, ARB for severe symptomatic AR without immediate plans for surgery

 

 

Bicuspid Aortic Valve

  • Surgical intervention:
    • Aortic root 5.5 cm
    • Aortic root 5 cm + risk factors (+ family history or > 0.5 cm/yr)
    • AVR indication + > 4.5 cm aorta
  • Bicuspid AoV + HTN  –> think coarctation
  • Bicuspid AoV + chest pain  –>   dissection

 

References:

Enriquez-Sarano M, Tajik AJ.  Aortic Regurgitation.  The New England Journal of Medicine.  2004;351: 1539-46.

Feldman T and Grossman W.  “Profiles in Valvular Heart Disease.” Chapter 28 in Cardiac Catheterization, Angiography, and Intervention.  New York:  Lippincott Williams & Wilkins, 2006.

Nishimura RA, et al.  2014 AHA/ACC Guideline for the Management of Patients with Valvular Heart Disease.  J Am Coll Cardiol. 2014 Jun 10;63(22):2438-88.

Oh JK, Seward JB, and Tajik AJ.  The Echo Manual.  New York: Lippincott Williams & Wilkins, 2007.

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Disclaimer     © 2015 www.markmccauleymd.com.  All rights served.