Georgia 2009: IDP Camp
Aortic Regurgitation
Jen McEntee, MD, MPH
Etiology of Acute and Chronic Aortic Regurgitation
ETIOLOGIES:
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Acquired - Bacterial Endocarditis, Ankylosing
Spondylitis, Trauma, anorectic drugs
(fenfluramine and dexfenfluramine)
Congenital/Genetic - Marfan Syndrome, EhlersDanlos, Hurler, VSD, Aortic Dissection, bicuspid
valve, Osteogenesis Imperfecta, Giant Cell
Arteritis, Reiter’s Syndrome,
Degenerative - cystic medial necrosis,
myxomatous degeneration, anuloaortic ectasia
Pathophysiology of Acute AR
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Sudden large regurgitant volume --> LV normal
size and not dilated --> increase end Diastolic
Volume --> decrease forward stroke volume -->
tachycardia to maintain CO --> hypotension and
Cardiogenic Shock and/or Pulmonary Edema
Pathophysiology of Chronic AR
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Increased regurg vol --> increases left
ventricular diastolic volume --> LV
enlargement --> LV hypertrophy -->
maintains stroke volume and CO
Clinical Presentation & Diagnosis:
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Acute AR:
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PE: ? Murmur - most likely low-pitched early diastolic murmur
and soft systolic murmur , narrow pulse pressure (2/2 to
decrease systolic pressure and increase diastolic pressure)
Pulmonary Edema, Cardiogenic shock, tachycardia, MI
EKG - nonspecific ST and T wave changes
CXR - ? Pulmonary edema, ? LV enlargement
TTE - diagnostic test of choice
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Severe Acute AR Echo findings = Vena contracta width > 6 mm,
Presence of holodiastolic flow reversal in descending
thoracic/proximal abd aorta, Regurg volume >60 ml/beat, regurg
fraction > 50%
Further Imaging if needed
Clinical Presentation of Chronic AR
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Chronic AR - asymptomatic for decades
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Sx - related to LVH, angina uncommon
PE :
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Widened Pulse Pressure,
Bounding pulses: Head Bobbing (deMusset’s sign), Traube’s sign
(pistol shot pulse heard over femoral artery), Quincke’s pulses
(cap pulsations in fingertips or lips), Mueller’s sign (uvular sys
pulsations), Becker’s sign (visible pulsations of ret arteries and
pupils), Rosenbach’s and Gerhard’s sign (pulsations over liver and
spleen respectively)
High -pitched, decrescendo, blowing Diastolic Murmur, Systolic
Murmur, Austin Flint murmur
Diagnosis of Chronic AR
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EKG - LVH with concurrent ST and T wave changes,
LAH, Left Axis
CXR - cardiomegaly, ? Widened mediastinum
ECHO - ECHO - ECHO - ECHO - ECHO - ECHO
Cardiac Catheterization - w/ aortic root angiography
and LV pressure measurement when TTE
inconclusive or discordant with clinical findings and
before AVR in pts at risk for CAD.
TREATMENT:
SURGERY VS MEDICAL MANAGEMENT
J McEntee
Management for Acute AR
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Medical Emergency
Surgery - AVR
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If delay in surgery - venodilators and +inotrope
Treat underlying etiology - endocarditis
Management of Chronic AR
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Serial Exams:
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Asymptomatic mild to moderate AR --> after first visit if
chronic AR is uncertain repeat TTE and PE in 2-3 months
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Asymptomatic mild with no LV dilatation and EF >55% -->
Yearly PE --> TTE q 2-3 years
Asymptomatic Severe AR with EF > 55% but LV EDD >
70 or LV ESD > 50 --> repeat TTE q 6-12 months
Symptomatic and EF < 25% or EDD >60 - ???
Surgical Management - AVR
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Class I - Evidence supports AVR
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Symptomatic w/ Severe AR
Asymptomatic w/ Severe AR and EF <50%
Severe AR and undergoing CABG or other valve repair
Class II
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IIa (reasonable)- Asymptomatic Severe AR w/ normal EF
but w/ LVD (EDD >75 mm or ESD > 55mm)
IIb (may be considered) - moderate AR while undergoing
surgery on ascending aorta or CABG, Asymptomatic
Severe AR w/ normal EF but w/ LVD (EDD >70 mm or
ESD > 50mm) and exercise intolerance.
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
Medical Therapy:
vasodilators
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Class I (indicated) - Severe AR with Symptoms or
EF < 50% but surgery not recommended
Class IIa (reasonable) - short-term tx to improve
cardiac function prior to AVR in pts with severe
AR with Symptoms and EF < 50%
Class IIb (may be considered) - long-term tx
asymptomatic severe AR with normal EF but LVD
Post-op Monitoring and Prognosis
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Post-op Monitoring
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TTE prior to pt DC and decreased LVD--> follow clinically
6-12 months
Persistent LVD --> treat with beta blockers and ACE-I -->
re-evaluation with TTE and clinically in 6-12 months
Prognosis
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Good predictor is decrease in LV EDD (80% reduction in
10-14 days post-op)
Our Pt
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AORTIC VALVE REPLACEMENT WITH
BIOPROSTHETIC VALVE
AORTA GRAFT
Post op complications with dev of atrial
flutter --> cardioverted to SR
Repeat TTE -->
POINTS TO PONDER
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Indications for surgery - Symptoms, EF <50, LV EDD > 75
mm, LV ESD > 55,
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BB contraindicated in acute and severe AR (even though
treatment in Aortic Dissection)
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Pt’s can always surprise you - the H and P is the most
important art of medicine.
References
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G. Hicks Jr. and H.T. Massey. Update on indications for surgery in aortic insufficiency. Current
Opinion Cardiology 2002, 17:172-178.
M. Enriquez-Sarano and A.J Tajik. Aortic Regurgitation. The New England Journal of Medicine.
October 7, 2004, 351:15; 1539-1546.
F. Kerendi, R. Guyton, J.D. Vega, P.D. Kilgo, and E.P. Chen. Early Results of Valve-Sparing
Aortic Root Replacement in High-Risk Clinical Scenarios. Ann Thorac Surg 2010; 89; 471-478.
Bonow et al. ACC/AHA VHD Guidelines: 2008 Focused Update Incorporated. JACC Vol. 52, No
13, 2008. September 23, 2008: e 1-e142.
UTD: Auscultation of Heart Murmurs,