1. Aortic regurgitation

2. 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

3. Normal LV Ejection Dynamics
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4. LV Ejection in Acute AR
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5. LV Ejection in Acute AR
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6. 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

7. LV Ejection in Chronic Compensated AR
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8. LV Ejection in Chronic Compensated AR
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9. LV Ejection in Chronic Decompensated AR
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10. LV Ejection in Chronic Decompensated AR
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11. LV Ejection in Chronic Decompensated AR
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12. 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
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13. LV remodeling in AR: eccentric hypertrophy
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14. 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

15. 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
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16. 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.
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17. 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
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18. Echo in AR: gives information needed to manage
Magnitude of regurgitation
Etiology of regurgitation
Left ventricular function
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19. Chronic Severe Aortic Regurgitation
© Eli Gelfand, MD // 2007