Sandbox/AIRSG

Jump to navigation Jump to search


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Overview

Aortic insufficiency (AI) refers to the retrograde or backward flow of blood from the aorta into the left ventricle during diastole.[1][2][3][4] Aortic insufficiency can be an acute or chronic illnes and both differ in the causes and management. The most common causes of acute AI are aortic dissection and infective endocarditis and the preffered treatment in both cases surgical intervention. The most common cause of chronic AI is bicuspid aortic valve and the treatment will depend on the stage of the disease in which the patient is. Acute AI is a life-threatening condition and must be recognized and treated promptly.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. The algorithm below is based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease.[6][7]

Boxes in red signify that an urgent management is needed.

 
 
 
 
 
 
 
 
 
 
Identify cardinal findings that increase the pretest probability of acute aortic regurgitation

❑ ❑
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any of the following findings that require urgent management?

Tachycardia
Hypotension
Loss of consciousness
Tachypnea

 
 
 
 
 
 
 
 
 

Diagnosis

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[6][7]

Abbreviations: BP: blood pressure; CXR: chest X-ray; ECG: electrocardiogram; LV: left ventricle

 
 
 
Characterize the symptoms:

Acute
❑ Sudden and severe dyspnea
Chest pain
Palpitations

Chronic
Dyspnea on exertion
Orthopnea
Paroxysmal nocturnal dyspnea
Palpitations
Chest pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inquire about past medical history:
❑ Previously healthy
Cardiac disease:
Hypertension
Bicuspid aortic valve
Rheumatic fever
Pulmonary disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Vitals
❑ Heart rate: tachycardia may be present to compensate for a reduced stroke volume
❑ Blood pressure: wide pulse pressure (systolic BP - diastolic BP ≥ 60 mmHg)

Cardiovascular examination
❑ Pulses

Corrigan's pulse:A rapid upstroke and collapse of the carotid artery pulse

❑ Cardiac auscultation

❑ Early diastolic decrescendo murmur
❑ Best heard at the upper left sternal border
❑ Murmur increases with: sitting forward, expiration and handgrip
S3 may be present (suggestive of left ventricular dysfunction)
Austin Flint murmur: a soft mid-diastolic rumble, best heard at the cardiac apex
Traube's sign: systolic and diastolic murmurs described as 'pistol shots' heard over the femoral artery when it is gradually compressed

❑ Search for other signs suggestive of aortic insufficiency

Müller's sign: systolic pulsations of uvula
de Musset's sign: head bobbing with each heart beat [8]
Hill's sign: ≥ 20 mmHg difference in popliteal and brachial systolic cuff pressures, seen in chronic severe AR
Quincke's sign: Pulsation of the capillary bed in the nail

Respiratory examination

Rales (seen when congestive heart failure has developed)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order imaging studies:

Chest X-ray

❑ Increase cardiac silhouette (suggestive of aortic dissection)
Widened mediastinum (suggestive of aortic root dilation)
❑ Pulmonary congestion (suggestive of HF)

ECG

❑ Nonspecific changes of ST and T wave (due to LV enlargement)
Right coronary artery ischemic changes (suggestive of aortic dissection)

TTE

Assess the following:
❑ Valve morphology
❑ Pressure gradient
❑ Aortic valve area
❑ Ejection fraction
❑ LV wall thickness and motility
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute


 
 
 
Chronic


 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Continue with the treatment of acute aortic insufficiency
 
 
 
Interpret the results from TTE
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Risk of AI (Stage A)

 
Mild to moderate (Stage B)


 
Asymptomatic severe (Stage C)


 
Symptomatic severe (Stage D)


 
 

Treatment

Treatment of Acute Aortic Insufficiency

Shown below is an algorithm for the treatment of acute aortic insufficiency according to the 2014 AHA/ACC Guidelines on the management of valvular heart disease.[1][2][3][4]

 
 
 
 
 
 
 
Treatment

❑ The use of nitroprusside and inotropic agents (such as: dopamine and dobutamine) help reduce the LV end-diastolic pressure before surgery
Avoid the use of beta blockers because may block compensating tachycardia

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mild or moderate
 
 
 
Severe
 
 
 
 
 
Urgent surgical intervention

❑ Aortic valve replacement

Intra-aortic balloon counterpulsation is contraindicated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Antibiotic treatment
A complete list of pathogen specific antibiotics regimens with appropriate dosages and duration of treatment is available here
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Chronic Aortic Insufficiency

Shown below is an algorithm summarizing the treatment approach to chronic aortic insufficiency (AI) according to the 2008 and 2014 AHA/ACC guidelines on the managenent of valvular heart disease.[1][2][3][4]


Do's


Don'ts

❑ Do not use beta blockers in AI of causes other than AD as it will block the compensation tachycardia. ❑ Do not use intra-aortic baloon counterpulsation in severe acute AI as it will increase the aortic diastolic pressure and the regurgitant volume.

References

  1. 1.0 1.1 1.2 Connolly HM, Crary JL, McGoon MD; et al. (1997). "Valvular heart disease associated with fenfluramine-phentermine". N. Engl. J. Med. 337 (9): 581–8. doi:10.1056/NEJM199708283370901. PMID 9271479.
  2. 2.0 2.1 2.2 Weissman NJ (2001). "Appetite suppressants and valvular heart disease". Am. J. Med. Sci. 321 (4): 285–91. doi:10.1097/00000441-200104000-00008. PMID 11307869.
  3. 3.0 3.1 3.2 Schade R, Andersohn F, Suissa S, Haverkamp W, Garbe E (2007). "Dopamine agonists and the risk of cardiac-valve regurgitation". N. Engl. J. Med. 356 (1): 29–38. doi:10.1056/NEJMoa062222. PMID 17202453.
  4. 4.0 4.1 4.2 Zanettini R, Antonini A, Gatto G, Gentile R, Tesei S, Pezzoli G (2007). "Valvular heart disease and the use of dopamine agonists for Parkinson's disease". N. Engl. J. Med. 356 (1): 39–46. doi:10.1056/NEJMoa054830. PMID 17202454.
  5. Nishimura, RA. (2002). "Cardiology patient pages. Aortic valve disease". Circulation. 106 (7): 770–2. PMID 12176943. Unknown parameter |month= ignored (help)
  6. 6.0 6.1 "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.
  7. 7.0 7.1 Bonow, R. O.; Carabello, B. A.; Chatterjee, K.; de Leon, A. C.; Faxon, D. P.; Freed, M. D.; Gaasch, W. H.; Lytle, B. W.; Nishimura, R. A.; O'Gara, P. T.; O'Rourke, R. A.; Otto, C. M.; Shah, P. M.; Shanewise, J. S. (2008). "2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–e661. doi:10.1161/CIRCULATIONAHA.108.190748. ISSN 0009-7322.
  8. Williams BR, Steinberg JP (2006). "Images in clinical medicine. Müller's sign". The New England Journal of Medicine. 355 (3): e3. doi:10.1056/NEJMicm050642. PMID 16855259. Retrieved 2012-04-15. Unknown parameter |month= ignored (help)


Template:WikiDoc Sources