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Valvular Heart Disease Aortic Regurgitation

Valvular Heart Disease Aortic Regurgitation. Aortic Regurgitation. Etiology Physical Examination Assessing Severity Natural History Prognosis Timing of Surgery. Any conditions resulting in incompetent aortic leaflets Congenital Bicuspid valve Aortopathy Cystic medial necrosis

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Valvular Heart Disease Aortic Regurgitation

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  1. Valvular Heart Disease Aortic Regurgitation © Continuing Medical Implementation …...bridging the care gap

  2. Aortic Regurgitation • Etiology • Physical Examination • Assessing Severity • Natural History • Prognosis • Timing of Surgery © Continuing Medical Implementation …...bridging the care gap

  3. Any conditions resulting in incompetent aortic leaflets Congenital Bicuspid valve Aortopathy Cystic medial necrosis Collagen disorders (e.g. Marfan’s) Ehler-Danlos Osteogenesis imperfecta Pseudoxanthoma elasticum Acquired Rheumatic heart disease Dilated aorta (e.g. hypertension..) Degenerative Connective tissue disorders E.g. ankylosing spondylitis, rheumatoid arthritis, Reiter’s syndrome, Giant-cell arteritis ) Syphilis (chronic aortitis) Acute AI: aortic dissection, infective endocarditis, trauma Aortic Regurgitation:Etiology © Continuing Medical Implementation …...bridging the care gap

  4. Aortic Regurgitation:Symptoms • Dyspnea, orthopnea, PND • Chest pain. • Nocturnal angina >> exertional angina • ( diastolic aortic pressure and increased LVEDP thus  coronary artery diastolic flow) • With extreme reductions in diastolic pressures (e.g. < 40) may see angina © Continuing Medical Implementation …...bridging the care gap

  5. Quincke’s sign: capillary pulsation Corrigan’s sign: water hammer pulse Bisferiens pulse (AS/AR > AR) De Musset’s sign: systolic head bobbing Mueller’s sign: systolic pulsation of uvula Durosier’s sign: femoral retrograde bruits Traube’s sign: pistol shot femorals Hill’s sign:BP Lower extremity >BP Upper extremity by > 20 mm Hg - mild AR > 40 mm Hg – mod AR > 60 mm Hg – severe AR Peripheral Signs of Severe Aortic Regurgitation © Continuing Medical Implementation …...bridging the care gap

  6. Aortic Regurgitation: Physical Exam • Widened pulse pressure • Systolic – diastolic = pulse pressure • High pitched, blowing, decrescendo diastolic murmur at LSB • Best heard at end-expiration & leaning forward • Hands & Knee position S1S2 S1 © Continuing Medical Implementation …...bridging the care gap

  7. Apex: Enlarged Displaced Hyper-dynamic Palpable S3 Austin-Flint murmur Aortic diastolic murmur length correlates with severity (chronic AR) in acute AR murmur shortens as Aortic DP=LVEDP in acute AR - mitral pre-closure Central Signs of Severe Aortic Regurgitation © Continuing Medical Implementation …...bridging the care gap

  8. Assessing Severity of AR • Assess severity by impact on peripheral signs and LV •  peripheral signs =  severity •  LV =  severity • S3 • Austin -Flint • LVH • radiological cardiomegaly © Continuing Medical Implementation …...bridging the care gap

  9. Aortic Regurgitation: Natural History Asymptomatic %/Y • Normal LV function (~good prognosis) • Progression to symptoms or LV dysfunction < 6 • Progression to asymptomatic LV dysfunction < 3.5 • 75% 5-year survival • Sudden death < 0.2 • Abnormal LV function • Progression to cardiac symptoms 25 • Symptomatic (Poor prognosis) • Mortality > 10 TX: Medical  Surgery BEFORE LV dysfunction © Continuing Medical Implementation …...bridging the care gap Bonow RO, et al, JACC. 1998;32:1486.

  10. Echo Indications for Valve Replacement in Asymptomatic AR & MR © Continuing Medical Implementation …...bridging the care gap

  11. Indication for Valve Replacement in Aortic Regurgitation • ACC/AHA Class I • Symptomatic patients with preserved LVF (LVEF >50%) • Asymptomatic patients with mild to moderate LV dysfunction (EF 25-49%) • Patients undergoing CABG, aortic or other valvular surgery • ACC/AHA Class II a • Asymptomatic patients with preserved LVEF but severe LV dilatation (EDD>75 mm or ESD > 55mm) © Continuing Medical Implementation …...bridging the care gap

  12. Indication for Valve Replacement in Aortic Regurgitation • ACC/AHA Class II b • Patients with severe LV dysfunction (EF < 25%) • Asymptomatic patients with normal systolic func-tion at rest (EF >0.50) and progressi ve LV dilata-tion when the degree of dilatation is moderatelysevere (EDD 70 to 75 mm, ESD 50 to 55 mm). • ACC/AHA Class III • Asymptomatic patients with normal systolicf unction at rest (EF >0.50) and LV dilatation when the degree of dilatation is not severe (EDD <70 mm, ESD <50 mm). © Continuing Medical Implementation …...bridging the care gap

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