Georgia 2009: IDP Camp Aortic Regurgitation Jen McEntee, MD, MPH.

Georgia 2009: IDP Camp

Aortic Regurgitation

Jen McEntee, MD, MPH

Etiology of Acute and Chronic Aortic Regurgitation

ETIOLOGIES: Acquired - Bacterial Endocarditis, Ankylosing

Spondylitis, Trauma, anorectic drugs (fenfluramine and dexfenfluramine)

Congenital/Genetic - Marfan Syndrome, Ehlers-Danlos, 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 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 Increased regurg vol --> increases left

ventricular diastolic volume --> LV enlargement --> LV hypertrophy --> maintains stroke volume and CO

Clinical Presentation & Diagnosis: Acute AR:

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

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

Chronic AR - asymptomatic for decades Sx - related to LVH, angina uncommon PE :

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 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.

J McEntee

TREATMENT:

SURGERY VS MEDICAL MANAGEMENT

Management for Acute AR Medical Emergency Surgery - AVR

If delay in surgery - venodilators and +inotrope

Treat underlying etiology - endocarditis

Management of Chronic AR Serial Exams:

Asymptomatic mild to moderate AR --> after first visit if chronic AR is uncertain repeat TTE and PE in 2-3 months

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 Class I - Evidence supports AVR

Symptomatic w/ Severe AR Asymptomatic w/ Severe AR and EF <50% Severe AR and undergoing CABG or other valve repair

Class II 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

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 Post-op Monitoring

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 Good predictor is decrease in LV EDD (80% reduction in

10-14 days post-op)

Our Pt AORTIC VALVE REPLACEMENT WITH

BIOPROSTHETIC VALVE AORTA GRAFT Post op complications with dev of atrial

flutter --> cardioverted to SR Repeat TTE -->

POINTS TO PONDER Indications for surgery - Symptoms, EF <50, LV EDD > 75

mm, LV ESD > 55,

BB contraindicated in acute and severe AR (even though treatment in Aortic Dissection)

Pt’s can always surprise you - the H and P is the most important art of medicine.

References 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,