1. AORTIC REGURGITATION

2. LEAFLETS: RHEUMATIC H.D. CALCIFIED PROLAPSE ENDOCARDITIS TRAUMA RHEUMATOID ARTHRITIS ANNULUS , ROOT MARFAN ANNULOAORTIC ECTASIA SYPHILLIS ANKYLOSING SPONDYLITIS DISSECTION AORTIC REGURGITATIONETIOLOGY

3. AORTIC INCOMPETENCE- ETIOLOGY

4. AORTIC INCOMPETENCE- ETIOLOGY

5. AORTIC REGURGITATIONPATHOPHYSIOLOGY L.V.MASS + + + ECCENTRIC LVH L.V.E.D.P. + + + • VOLUME OVERLOAD : AORTA L.V.

6. AORTIC REGURGITATIONPATHOPHYSIOLOGY

7. AORTIC REGURGITATIONSYMPTOMS • CONGESTIVE HEART FAILURE • ANGINA PECTORIS AFTER LONG LATENT PERIOD

8. AORTIC REGURGITAIONPHYSICAL EXAMINATION 1 • PULSE : COLLAPSING (CORRIGAN WATERHAMMER) • DE MUSSET • QUINCKE • DUROZIER • APEX : DISPLACED + + + + DILATED + + + + COR BOVINUM

9. AORTIC REGURGITATIONDUROZIER SIGN FEMORAL ART. LISTEN TO DIASTOLIC MURMUR!

10. AORTIC REGURGITATIONPHYSICAL EXAMINATION 2 AUSCULTATION S4 M.S.M. E.D.M. S3 S1 S(P)2

11. AORTIC REGURGITATIONEVALUATION • 1. PHYSICAL EXAMINATION: APEX LENGTH OF MURMUR! DUROZIER • 2. ECHODOPPLER: L.V. SIZE WIDTH OF COLOR JET

12. Aortic Incompetence- ECG Left Ventricular Hypertrophy & Strain , Wide QRS

13. AORTIC REGURGITATION ECHODOPPLER

14. BICUSPID AORTIC VALVE TRANSESOPHAGEAL ECHO

15. Continuous-wave spectral recordings of patients with mild (top) and severe (bottom) aortic insufficiency. Note the relatively flat slope pressure decay and faint spectral signal intensity in the mild insufficiency and a denser spectral signal and steeper slope of pressure decay,denoting near equalization of aortic and left ventricular diastolic pressures,seen in severe aortic insufficiency. AORTIC REGURGITATION ECHODOPPLER

16. Bonow and associates (blue line) and Borer and colleagues (magenta line), each enrolling 104 patients. At 11 years, 45 to 58 percent of patients remained asymptomatic with normal LV function, such that the risk of developing symptoms, LV dysfunction, or death is 4 to 6 percent per year. AORTIC REGURGITATIONNATURAL HISTORY

17. Survival without surgery in 242 patients with chronic aortic regurgitation, demonstrating the importance of symptoms in determining outcome. AORTIC REGURGITATIONNATURAL HISTORY

18. AORTIC REGURGITATIONTREATMENT 1 • VASODILATORS • DIURETICS • DIGOXIN • AORTIC VALVE REPLACEMENT

19. Randomized clinical trial of nifedipine versus digoxin in asymptomatic patients with chronic aortic regurgitation and normal left ventricular (LV) function. AORTIC REGURGITATIONTREATMENT 2

20. AORTIC REGURGITATIONTREATMENT 3 • INDICATIONS FOR SURGERY : • SYMPTOMS • L.V. DILATATION > 7.5 / 5.5 CM • INTRA AORTIC BALLOON PUMP CONTRAINDICATED!!!!

21. ACC/AHA LVEF < 49% (classI) L.E.S.D. >55mm (classII) ESC LVEF < 50% L.E.S.D. > 50mm L.E.D.D. > 70mm INDICATION FOR AVR IN ASYMPTOMATIC PATIENTS WITH A.R.

22. Long-term postoperative survival in patients with aortic regurgitation, stratified according to the severity of preoperative symptoms and preoperative left ventricular ejection fraction AORTIC REGURGITATIONTREATMENT 4

23. AORTIC REGURGITATIONTREATMENT 5 The same for patients with LVEF < 50%

24. . The St. Jude bileaflet valve. PROSTHETIC MECHANICAL VALVES Starr-Edwards caged-ball valve The Medtronic-Hall valve

25. PROSTHETIC BIOLOGICAL VALVES

26. ACUTE AORTIC REGURGITATION 1 • SHOCK • TACHYCARDIA • PULMONARY EDEMA • NO PERIPHERAL SIGNS • SHORT E.D.M. • S3

27. ACUTE AORTIC REGURGITATION 2 • HIGH INDEX OF SUSPICION!! • ECHODOPPLER • CATHETERIZATION - HEMODYNAMICS AORTOGRAM

28. תודה מכל הלב!!