1. 2007 Aortic Regurgitation

2. Definition Failure of aortic leaflet cooptation in diastole Chronic Aortic Regurgitation

3. Cusps Disease Aortic Root Disease Chronic Aortic Regurgitation - Etiology

4. Cusps Disease Endocarditis Bicuspid AV (10% pure AR). Rheumatic Heart Disease (usually with MV disease but sometimes can be the dominant lesion). Calcification of cusps (Degenerative). Chronic Aortic Regurgitation - Etiology

5. Chronic Aortic Regurgitation - BAV

6. Aortic Root Disease Atherosclerosis Marfan’s syndrome (dilatation of sinotubular ridge lifts the cusps). Aortic dissection. Syphilitic aortitis. Ankylosis spondilitis. Systemic lupus. Chronic Aortic Regurgitation - Etiology

7. Chronic Aortic Regurgitation

8. Aortic Regurgitation

9. Initially chronic AR leads to a small increase in LV end diastolic volume and a small increase in stroke volume. Large regurgitant volume increases LV end diastolic pressure (pulmonary congestion). If developed slowly, AR enters a chronic phase of eccentric hypertrophy and progressive LV dilatation and increased stroke volume (pulse pressure) a combined pressure and volume overload), and may remain compensated for many years till LV dysfunction eventually develops. Aortic Regurgitation - Aortic Regurgitation - Pathophysiology

10. In AR there is not only volume overload but also an increase in afterload and systolic wall stress. This distinguishes AR from mitral regurgitation where systolic wall stress is normal or even low, since the regurgitant blood is ejected into the low pressure left atrium. Thus valve surgery in MR usually results in an increase in afterload and commonly in worsening of the LV ejection fraction, correction of AR results in a decrease in afterload and frequently an improvement of the ejection fraction. Aortic Regurgitation - Aortic Regurgitation - Pathophysiology Post op, if performed on time remodeling occur and LV dimensions become smaller, without LV dysfunction..

11. Aortic Regurgitation

12. Congestive Heart Failure After a long compensated phase (many years), LV decompensation proceeds symptoms of dyspnea, orthopnea and peripheral edema. Angina Diastolic hypotension can impair coronary flow. Increase demand on coronary flow d/t increased LV mass. Less common than in aortic stenosis. Chronic Aortic Regurgitation – Clinical Symptoms

13. Bounding pulses (chronic AR). Diastolic decrescendo murmur (length correlates with severity when LV function is good) in left sternal border. Systolic murmur due to relative aortic stenosis. Mitral rumble (Austin Flint murmur), jet impinging the mitral valve. Systolic hypertension and wide pulse pressure (mod-sev AR). Signs become less apparent with decompensation and S3 appears. Chronic Aortic Regurgitation – Physical Findings

14. Signs of aortic insufficiency SignFinding Corrigan ’ s pulse Rapid forceful carotid upstroke followed by rapid decline Quincke ’ s sign Systolic plethora and diastolic blanching in nail bed when nail is slightly compressed De Musset ’ s sign Bobbing of head Duroziez ’ s sign Systolic and diastolic bruit heard over femoral artery when compressed by bell of stethoscope Hill ’ s sign Augmentation of systolic blood pressure in the arm by 30 mmHg compared to the leg Chronic Aortic Regurgitation - Signs

15. LV size and function, aortic root and cusps motion. Typical cusps morphology in different etiologies. Color Doppler interrogation of regurgitant flow in LVOT, jet width to estimate severity (semi quantitative). Descending aortic flow reversal in the aorta in diastole. Pressure half time of aortic regurgitant flow, more rapid in severe cases. When echocardiography is not available or clear MRI is an alternative for assessment of valve morphology and flow, and LV function and nuclear angiography can be used for serial assessment of LV function. Chronic Aortic Regurgitation - Echocardiography

16. Chronic Aortic Regurgitation

18. Echocardiographic Criteria of Severity of Aortic Regurgitation (color flow jet width) Jet width (vena contracta) Jet / LVOTSeverity < 3 mm<25%Mild 3-6 mm25%-65%Moderate > 6 mm>65%Severe Chronic Aortic Regurgitation

20. For controversial cases and patients above 40 and those with risk factors with suspected coronary artery disease. Aortography visualizes flow of contrast media (not velocities like echocardiography), the denser the ventricle opacification the worse is the regurgitation. Chronic Aortic Regurgitation – Cardiac Catheterization

21. Chronic Aortic Regurgitation - Management Exercise Testing Assessment of functional capacity and symptomatic response when with history of equivocal symptoms. Before participation in athletic activities For prognostic assessment before AVR in patients with LV dysfunction.

22. A diminished LV ejection fraction (below 50 – 55%) is associated with reduced prognosis even in asymptomatic patients (A). LV enlargement in and of itself also constitutes an indication for surgery (B). Chronic Aortic Regurgitation - Management

23. Surgery Recomended After symptoms and before dysfunction is irreversible. With evidence of contractile dysfunction even if asymptomatic. Ecocardiographic Criteria for surgery with Severe AR Simple measures of contractility: shortening fraction (<27%) and ejection fraction (<55%). LV end systolic diameter (>5.0 cm). LV end-systolic volume >55 mL/m 2 A window of 18 months is available once those limits are crossed. Repeat measures (LVEDD 5.0 – 6 m). Chronic Aortic Regurgitation - Management

24. The overall operative mortality for isolated AVR is about 4.3%. In patients with marked cardiac enlargement and prolonged LV dysfunction experience an operative mortality rate of approximately 10% and a late mortality rate of approximately 5% per year due to LV failure despite a technically satisfactory operation. Because of the very poor prognosis with medical management, even patients with LV failure should be considered for operation. Chronic Aortic Regurgitation - Management

25. AV replacement (with/without root replacement) AV repair: (annular dilatation, valve perforation, non calcified leaflets with prolapse) Medical Therapy Vasodilators; Nifedipine, hydralazine, ACE inhibitors are used to delay progression of AR in asymptomatic patients. (more compelling data is available with nifedipine). Chronic Aortic Regurgitation - Management

26. Chronic Aortic Regurgitation

27. Background Medical emergency (mortality 75% with medical therapy, 25% with surgery). Etiology Endocarditis Aortic dissection Trauma Acute Aortic Regurgitation

28. Echocardiography Early closure of mitral valve. Diastolic mitral regurgitation. Vegetation, intimal tear. Consider TEE (for vegetations, abscess, aortic dissection). Management Blood culture, antibiotics, vasodilators AVR (10% risk of reinfection). Aortic Regurgitation - Diagnosis

29. Aortic Regurgitation - Guidelines AHA ACC 2006 European 2007 AR קשה, חולים סימפטומטים דרגה תפקודית 2-4 II AR קשה ופגיעה בחדר שמאל (LVEF<50%) II AR קשה, מתוכנן ניתוח CABG/ מסתם אחר / האורטה העולה II AR קשה, חולים אסימפטומטים עם LVEF מעל 50%, חדר מאד מורחב IIa LV>75/55 IIa LV>70/50 AR קשה, חולים אסימפטומטים עם LVEF מעל 50%, חדר מורחב במידה בינונית (70-75/50-55 מ " מ ) IIb-

30. Aortic Regurgitation - Guidelines AHA ACC 2006 European 2007 AR בכל דרגה, האורטה מורחבת : מרפאן  45 מ " מ מסתם דו - עלי  50 מ " מ שאר המסתמים <55 מ " מ מעל 50 ממ בכל האטיולוגיות I IIa קוטר האורטה העולה

31. NATURAL HISTORY OF AORTIC REGURGITATION Asymptomatic patients with normal LV systolic function: <6%/yr Progression to symptoms and/or LV dysfunction <3.5%/yr Progression to asymptomatic LV dysfunction <0.2%/yr Sudden death Asymptomatic patients with LV systolic dysfunction: >25%/yr Progression to cardiac symptoms Symptomatic patients: >10%/yr Mortality rate LV = left ventricular. From Bonow RO, Carabello B, de Leon AC Jr, et al: ACC/AHA Guidelines for the management of patients with valvular heart disease. J Am Coll Cardiol 32:1486, 1998.