Aortic regurgitation
Causes of aortic regurgitation Some common causes: Calcific degeneration Hypertension These can cause acute aortic regurgitation: Endocarditis Marfan’s syndrome Aortic dissection © Eli Gelfand, MD // 2007
Normal LV Ejection Dynamics © Eli Gelfand, MD // 2007
LV Ejection in Acute AR © Eli Gelfand, MD // 2007
LV Ejection in Acute AR © Eli Gelfand, MD // 2007
What to do when you are encountered with this situation? If the patient is not hypotensive, can consider short acting vasodilators. Intra-aortic balloon pump is contraindicated Needs to go urgently to surgery to have the valve replaced
LV Ejection in Chronic Compensated AR © Eli Gelfand, MD // 2007
LV Ejection in Chronic Compensated AR © Eli Gelfand, MD // 2007
LV Ejection in Chronic Decompensated AR © Eli Gelfand, MD // 2007
LV Ejection in Chronic Decompensated AR © Eli Gelfand, MD // 2007
LV Ejection in Chronic Decompensated AR © Eli Gelfand, MD // 2007
Eccentric hypertrophy Concentric remodeling Concentric hypertrophy LV remodeling Cavity size normal LV mass normal Normal Cavity size increased LV mass increased Eccentric hypertrophy Concentric remodeling Cavity size small Concentric hypertrophy © Eli Gelfand, MD // 2007 12
LV remodeling in AR: eccentric hypertrophy © Eli Gelfand, MD // 2007 13
Symptoms and exam findings Chronic aortic regurgitations is usually asymptomatic for a long time After LV dysfunction develops, patient gradually experiences symptoms related to pulmonary congestion such as increased dypsnea with exertion, orthopnea, and PND Physical exam findings: Peripheral pulse: the increased total stroke volume leads to an abrupt increase in arterial pressure during systole followed by a rapid fall during diastole. There is a widened pulse pressure and a hyperdynamic pulse. Cardiac palpation: the apical impulse is enalged and displaced laterally Cardiac auscultation: the hall mark of AR is a blowing, diastolic, decrescendo murmur that is best heard in the left upper sternal border with the patient leaning forward at full expiration. The severity correlates with the duration of the murmur Mild AR- short Severe AR-long
Some statistics to cite to patients with severe AR Asymptomatic patients with normal LV function Progression to symptoms or LV dysfunction <6% per year Progression to asymptomatic LV dysfunction <3.5% per year Sudden death <0.2% per year Asymptomatic patients with LV dysfunction Progression to cardiac symptoms >25% per year Symptomatic patients Mortality >10% per year © Eli Gelfand, MD // 2007 15
Medical management of severe AR Large stroke volume and wide pulse pressure ↑↑ afterload Data on vasodilators: Nifedipine vs. digoxin (no placebo; Scognamiglio et al., 1994) Nifedipine better – delay in development of symptoms or need for AVR Nifedipine vs. enalapril vs. placebo (Evangelista, 2005) No difference in need for AVR Nifedipine did not affect any measured variable (BP, LV geometry) ACC/AHA guidelines for vasodilator treatment Symptomatic patients who are not surgical candidates Asymptomatic AR patients with LV dilatation but normal EF. Asymptomatic AR patients with hypertension. © Eli Gelfand, MD // 2007 16
AVR: indications Symptoms attributable to severe AR Asymptomatic patients with: LV dysfunction at rest (EF <50%) Marked LV dilation ESD > 55 mm EDD > 75 mm Severely dilated aortic root Patients with severe AR, who undergo other cardiac or aortic surgery © Eli Gelfand, MD // 2007 17
Echo in AR: gives information needed to manage Magnitude of regurgitation Etiology of regurgitation Left ventricular function © Eli Gelfand, MD // 2007
Chronic Severe Aortic Regurgitation © Eli Gelfand, MD // 2007