Sandbox/AIRSG
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]
Aortic Regurgitation Resident Survival Guide Microchapters |
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Overview |
Causes |
FIRE |
Diagnosis |
Treatment |
Do's |
Don'ts |
Overview
Aortic regurgitation (AR) refers to the retrograde or backward flow of blood from the aorta into the left ventricle during diastole.[1][2][3][4] The presentation depends on the response and adaptability of the left ventricle to the increased diastolic volume, in chronic AR the left ventricle has adapted by dilatation of its walls. However, in acute AR, a rapid increase in the diastolic volume is not tolerated by a normal size ventricle and this could lead to cardiogenic shock. The most common causes of acute aortic regurgitation are aortic dissection and infective endocarditis and the preferred treatment in both cases surgical intervention. The most common cause of chronic AR is bicuspid aortic valve and the treatment will depend on the stage of the disease. Acute AR 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
- Bicuspid aortic valve
- Senile or degenerative calcific aortic valve disease[5]
- Hypertension
- Idiopathic dilatation of the aorta
- Myxomatous degeneration
- Rheumatic fever
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 salmon color signify that an urgent management is needed.
Identify cardinal findings that increase the pretest probability of aortic regurgitation Acute AR ❑ Low pitched early diastolic murmur
❑ Decreased or absent S1
❑ Corrigan's pulse: a rapid upstroke and collapse of the carotid artery pulse | |||||||||||||||||||||||||||||||||||||
Does the patient have any of the following findings that require urgent management? ❑ Tachycardia ❑ Hypotension ❑ Altered mental status ❑ Tachypnea ❑ Oliguria ❑ Cold extremities | |||||||||||||||||||||||||||||||||||||
YES | NO | ||||||||||||||||||||||||||||||||||||
Initiate resuscitation measures: ❑ Secure airway ❑ Administer oxygen ❑ 2 wide bore IV access ❑ ECG monitor ❑ Monitor vitals continuously ❑ ICU admission Order transthoracic echocardiography (TTE) (urgent)
| Continue with complete diagnostic approach | ||||||||||||||||||||||||||||||||||||
What is the etiology based on clinical findings and TTE? | |||||||||||||||||||||||||||||||||||||
Diagnostic clues: ❑ Chest pain of the following characteristics:
❑ Syncope
❑ Previous history of: | Diagnostic clues: ❑ Persistent fever ❑ New valvular regurgitation murmur ❑ Positive blood culture ❑ Vegetations found on TTE ❑ High risk factors:
| {{{ D03 }}} | |||||||||||||||||||||||||||||||||||
Click here for aortic dissection resident survival guide | Click here for infective endocarditis resident survival guide | ||||||||||||||||||||||||||||||||||||
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; MI: myocardial infarction; TTE: transthoracic echocardiography; TEE: transesophageal echocardiography; TAVR: transcatheter aortic valve replacement; S1: first heart sound; S2: second heart sound; S3: third heart sound; CCB: calcium channel blocker; ACE: angiotensin converting enzyme; ARB: angiotensin receptor blocker
Acute Aortic Regurgitation
Characterize the symptoms: ❑ Sudden and severe dyspnea
❑ Syncope ❑ Weakness ❑ Myalgias | |||||||||||||||||||||||||||||||||||||||||||
Inquire about past medical history: ❑ Cardiac disease: ❑ Rheumatic fever
| |||||||||||||||||||||||||||||||||||||||||||
Examine the patient: Vitals
❑ Heart rate:
Cardiovascular examination
Respiratory examination | |||||||||||||||||||||||||||||||||||||||||||
Order labs and tests: ❑ TTE (most important evaluation test) (Class I; Level of Evidence: B)
❑ ECG
❑ Blood culture (if suspected infective endocarditis) ❑ Cardiac enzymes (Troponin, CK-MB) | |||||||||||||||||||||||||||||||||||||||||||
Determine the etiology of the acute aortic regurgitation | |||||||||||||||||||||||||||||||||||||||||||
Diagnostic clues: ❑ Chest pain of the following characteristics:
❑ Syncope
❑ Previous history of: | Diagnostic clues: ❑ Persistent fever ❑ New valvular regurgitation murmur ❑ Positive blood culture ❑ Vegetations found on TTE ❑ High risk factors:
| Other causes | |||||||||||||||||||||||||||||||||||||||||
Click here for aortic dissection resident survival guide | Click here for infective endocarditis resident survival guide | Treat the underlying cause of acute aortic regurgitation | |||||||||||||||||||||||||||||||||||||||||
Chronic Aortic Regurgitation
Characterize the symptoms: ❑ Dyspnea on exertion ❑ Orthopnea ❑ Paroxysmal nocturnal dyspnea ❑ Palpitations ❑ Chest pain | |||||||||||||||||||||||||||||||||||||||||||||
Examine the patient: Vitals
Cardiovascular examination
❑ Search for other signs suggestive of aortic regurgitation
Respiratory examination | |||||||||||||||||||||||||||||||||||||||||||||
Order imaging studies: ❑ TTE (most important evaluation test) (Class I; Level of Evidence: B)
❑ ECG | |||||||||||||||||||||||||||||||||||||||||||||
Classify aortic regurgitation based on the following findings on TTE: ❑ Vena contracta ❑ Jet/LVOT ❑ Regurgitant volume ❑ Regurgitant fraction ❑ Effective regurgitant orifice | |||||||||||||||||||||||||||||||||||||||||||||
❑ No regurgitation | Mild (Stage B) ❑ Vena contracta <0.3 cm ❑ Jet/LVOT <25% ❑ Regurgitant volume <30 mL/beat ❑ Regurgitant fraction <30% ❑ Effective regurgitant orifice <0.10 cm² | Moderate (Stage B) ❑ Vena contracta 0.3-0.6 cm ❑ Jet/LVOT 25-64% ❑ Regurgitant volume 30-59 mL/beat ❑ Regurgitant fraction 30-49% ❑ Effective regurgitant orifice 0.10-0.29 cm² | Severe ❑ Vena contracta >0.6 cm ❑ Jet/LVOT ≥ 65% ❑ Regurgitant volume ≥60 mL/beat ❑ Regurgitant fraction ≥50% ❑ Effective regurgitant orifice ≥ 0.30 cm² ❑ Holodiastolic flow reversal in the proximal abdominal aorta | ||||||||||||||||||||||||||||||||||||||||||
Asymptomatic | Symptomatic (Stage D) | ||||||||||||||||||||||||||||||||||||||||||||
Treatment
Acute Aortic Regurgitation
Shown below is an algorithm for the treatment of acute aortic regurgitation according to the 2014 AHA/ACC Guidelines for the Management of Valvular Heart Disease[6][9] and the 2010 ACCF/AHA Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease[10]
Determine the etiology and the grade of regurgitation | |||||||||||||||||||||||||||||||||
Mild or moderate regurgitation (Stage B) | Severe regurgitation (Stage C or D) | Mild or moderate regurgitation (Stage B) | Severe regurgitation (Stage C or D) | ||||||||||||||||||||||||||||||
Early mitral valve closure† is present? | Replacement of supra-coronary ascending aorta | Aortic root replacement, OR Valve-sparing aortic root replacement | |||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||
❑ ICU care ❑ Perform surgery if:
| If presence of mitral regurgitation:
❑ Perform surgery immediately (< 4 hours) If absence of mitral regurgitation: ❑ Perform surgery in less than 24 hours | ||||||||||||||||||||||||||||||||
† Early mitral valve closure refers to the closure of the mitral valve before the QRS due to an increased diastolic left ventricle pressure. Grade I occurs when it happens before QRS but after the P wave. Grade II is the mitral valve closure before the P wave. [9]
Chronic Aortic Regurgitation
Shown below is an algorithm summarizing the treatment approach to chronic aortic regurgitation according to the 2014 AHA/ACC Guidelines on the Management of Valvular Heart Disease.[6][7]
Interpret results from TTE | |||||||||||||||||||||||||||||||||||||||||||||||||||
No regurgitation (Stage A) | Progressive regurgitation (Stage B) Mild ❑ Vena contracta <0.3 cm ❑ Jet/LVOT <25% ❑ Regurgitant volume <30 mL/beat ❑ Regurgitant fraction <30% ❑ Effective regurgitant orifice <0.10 cm² Moderate ❑ Vena contracta 0.3-0.6 cm ❑ Jet/LVOT 25-64% ❑ Regurgitant volume 30-59 mL/beat ❑ Regurgitant fraction 30-49% ❑ Effective regurgitant orifice 0.10-0.29 cm² | Severe regurgitation ❑ Vena contracta >0.6 cm ❑ Jet/LVOT ≥ 65% ❑ Regurgitant volume ≥60 mL/beat ❑ Regurgitant fraction ≥50% ❑ Effective regurgitant orifice ≥ 0.30 cm² ❑ Holodiastolic flow reversal in the proximal abdominal aorta | |||||||||||||||||||||||||||||||||||||||||||||||||
Asymptomatic patients ❑ Control hypertension preferably with
| Asymptomatic (Stage C) | Symptomatic (Stage D) | |||||||||||||||||||||||||||||||||||||||||||||||||
❑ Perform a periodic echocardiogram (Class I; Level of Evidence:B)
| |||||||||||||||||||||||||||||||||||||||||||||||||||
Perform a periodic echocardiogram every 6 - 12 months (Class I; Level of Evidence: B) | ❑ Schedule for AVR (Class I; Level of Evidence: B) ❑ Administer ACE inhibitors/ARBs or beta blockers if patient has contraindications for surgery | ||||||||||||||||||||||||||||||||||||||||||||||||||
Choice of Intervention
Shown below is an algorithm summarizing the choice of the intervention to aortic stenosis based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease [6]
Patient scheduled for AVR | |||||||||||||||||||||||||||||||||
High risk | Low to moderate risk | ||||||||||||||||||||||||||||||||
❑ A multidisciplinary group should decide intervention (Surgical AVR or TAVR) (Class I; Level of Evidence: C) ❑ Schedule for TAVR (Class IIa; Level of Evidence: B)[6] [11] | ❑ Schedule for surgical AVR (Class I; Level of Evidence: A) | ||||||||||||||||||||||||||||||||
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
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Nishimura, RA. (2002). "Cardiology patient pages. Aortic valve disease". Circulation. 106 (7): 770–2. PMID 12176943. Unknown parameter
|month=
ignored (help) - ↑ 6.0 6.1 6.2 6.3 6.4 6.5 Nishimura, R. A.; Otto, C. M.; Bonow, R. O.; Carabello, B. A.; Erwin, J. P.; Guyton, R. A.; O'Gara, P. T.; Ruiz, C. E.; Skubas, N. J.; Sorajja, P.; Sundt, T. M.; Thomas, J. D. (2014). "2014 AHA/ACC Guideline 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". Circulation. doi:10.1161/CIR.0000000000000031. ISSN 0009-7322.
- ↑ 7.0 7.1 7.2 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.
- ↑ 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) - ↑ 9.0 9.1 Hamirani, Y. S.; Dietl, C. A.; Voyles, W.; Peralta, M.; Begay, D.; Raizada, V. (2012). "Acute Aortic Regurgitation". Circulation. 126 (9): 1121–1126. doi:10.1161/CIRCULATIONAHA.112.113993. ISSN 0009-7322.
- ↑ Hiratzka, L. F.; Bakris, G. L.; Beckman, J. A.; Bersin, R. M.; Carr, V. F.; Casey, D. E.; Eagle, K. A.; Hermann, L. K.; Isselbacher, E. M.; Kazerooni, E. A.; Kouchoukos, N. T.; Lytle, B. W.; Milewicz, D. M.; Reich, D. L.; Sen, S.; Shinn, J. A.; Svensson, L. G.; Williams, D. M. (2010). "2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine". Circulation. 121 (13): e266–e369. doi:10.1161/CIR.0b013e3181d4739e. ISSN 0009-7322.
- ↑ Smith, Craig R.; Leon, Martin B.; Mack, Michael J.; Miller, D. Craig; Moses, Jeffrey W.; Svensson, Lars G.; Tuzcu, E. Murat; Webb, John G.; Fontana, Gregory P.; Makkar, Raj R.; Williams, Mathew; Dewey, Todd; Kapadia, Samir; Babaliaros, Vasilis; Thourani, Vinod H.; Corso, Paul; Pichard, Augusto D.; Bavaria, Joseph E.; Herrmann, Howard C.; Akin, Jodi J.; Anderson, William N.; Wang, Duolao; Pocock, Stuart J. (2011). "Transcatheter versus Surgical Aortic-Valve Replacement in High-Risk Patients". New England Journal of Medicine. 364 (23): 2187–2198. doi:10.1056/NEJMoa1103510. ISSN 0028-4793.