2007

Aortic RegurgitationAortic Regurgitation

Definition• Failure of aortic leaflet cooptation in diastole

Chronic Aortic RegurgitationChronic Aortic Regurgitation

• Cusps Disease

• Aortic Root Disease

Chronic Aortic Regurgitation - EtiologyChronic Aortic Regurgitation - Etiology

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 - EtiologyChronic Aortic Regurgitation - Etiology

Chronic Aortic Regurgitation - BAVChronic Aortic Regurgitation - BAV

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 - EtiologyChronic Aortic Regurgitation - Etiology

Chronic Aortic RegurgitationChronic Aortic Regurgitation

Aortic RegurgitationAortic Regurgitation

• 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

• 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..

Aortic RegurgitationAortic Regurgitation

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 SymptomsChronic Aortic Regurgitation – Clinical Symptoms

• 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 FindingsChronic Aortic Regurgitation – Physical Findings

Signs of aortic insufficiency

Sign Finding

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 signAugmentation of systolic blood pressure in the arm by 30 mmHg compared to the leg

Chronic Aortic Regurgitation - SignsChronic Aortic Regurgitation - Signs

• 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 - EchocardiographyChronic Aortic Regurgitation - Echocardiography

Chronic Aortic RegurgitationChronic Aortic Regurgitation

Chronic Aortic RegurgitationChronic Aortic Regurgitation

Echocardiographic Criteria of Severity of Aortic Regurgitation

(color flow jet width)

SeverityJet / LVOTJet width)vena contracta(

Mild<25% <3 mm

Moderate25%-65%3-6 mm

Severe>65% >6 mm

Chronic Aortic RegurgitationChronic Aortic Regurgitation

Chronic Aortic RegurgitationChronic Aortic Regurgitation

• 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 RegurgitationChronic Aortic Regurgitation – –

Cardiac Catheterization

Chronic Aortic Regurgitation - ManagementChronic 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.

• 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 - ManagementChronic Aortic Regurgitation - Management

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/m2

• A window of 18 months is available once those limits are crossed. Repeat measures (LVEDD <4.0 – 2 y, 4.0-5.0 1 y, >5.0 – 6 m).

Chronic Aortic Regurgitation - ManagementChronic Aortic Regurgitation - Management

• 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 - ManagementChronic Aortic Regurgitation - Management

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 - ManagementChronic Aortic Regurgitation - Management

Chronic Aortic RegurgitationChronic Aortic Regurgitation

Background• Medical emergency (mortality 75% with medical

therapy, 25% with surgery).

Etiology• Endocarditis• Aortic dissection• Trauma

Acute Aortic RegurgitationAcute Aortic Regurgitation

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 - DiagnosisAortic Regurgitation - Diagnosis

Aortic Regurgitation - GuidelinesAortic Regurgitation - Guidelines

European 2007

AHA ACC 2006

IIAR חולים סימפטומטים דרגה קשה ,2-4תפקודית

IIAR ופגיעה בחדר שמאל קשה (LVEF<50% )

IIAR מתוכנן ניתוח קשה ,CABG /מסתם אחר/האורטה העולה

IIa

LV<70/50

IIa

LV<75/55

ARחולים אסימפטומטים עם קשה ,LVEF חדר מאד מורחב50% מעל ,

-IIb ARחולים אסימפטומטים עם קשה ,LVEF חדר מורחב במידה 50% מעל ,

מ"מ( 70-75/50-55 ) בינונית

Aortic Regurgitation - GuidelinesAortic Regurgitation - Guidelines

European 2007

AHA ACC 2006

I

IIa

IIa

50מעל ממ בכל האטיולוגיו

ת

AR בכל דרגה, האורטה מ"מ 45מורחבת: מרפאן

מ"מ 50מסתם דו-עלי

מ"מ 55שאר המסתמים >

קוטר האורטה העולה

NATURAL HISTORY OF AORTIC REGURGITATION

Asymptomatic patients with normal LV systolic function:

 

•Progression to symptoms and/or LV dysfunction <6%/yr

•Progression to asymptomatic LV dysfunction <3.5%/yr

•Sudden death <0.2%/yr

Asymptomatic patients with LV systolic dysfunction :

 

•Progression to cardiac symptoms >25%/yr

Symptomatic patients:  

•Mortality rate >10%/yr

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 .