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Acute Aortic Regurgitation

Acute aortic regurgitation (AAR) is a potentially fatal ailment, that entails the malfunction of the aortic valve. It has a number of etiologies, including infective and iatrogenic ones. This condition is more common in males.


Presentation

Acute aortic regurgitation (AAR) is a disease where the leaflets of the aortic valve fail to come together and close properly, leading to the backflow of blood. It has several causes, which may be infective, such as bacterial endocarditis, trauma-related, most often blunt trauma to the chest, inflammatory (nonbacterial endocarditis), and aortic dissection [1]. Less commonly, AAR is iatrogenic following cardiac surgery, or due to penetrating chest trauma. In addition, dysfunction of prosthetic valves may be a factor.

AAR may present with clinical features similar to those of heart failure or severe infection [2]. This may make the correct diagnosis of AAR more difficult, however, it is important that it is rightfully diagnosed, as it is an emergency. Furthermore, its prognosis is much poor than the chronic form of the disease [3] [4].

The main symptoms of AAR are vascular and in keeping with cardiac failure. Consequently, patients may experience dyspnea, chest pain, and general body weakness. The onset of AAR features such as chest pain and dyspnea is sudden [5]. Signs of the disease commonly include tachycardia, cyanosis, pulsus alternans, crepitations in the lungs indicating pulmonary edema and hypotension and peripheral vasoconstriction leading to cool extremities. Additionally, S1 may be absent, S3 may be present, with a concurrent murmur (Austin Flint murmur). The severity of symptoms varies. Cardiogenic shock may ensue, with multi-system organ failure.

Orthopnea
  • Another reason is the increased demand of oxygen by the hypertrophied left ventricle. [2] Features of Heart Failure (HF) Eg: Paroxysmal nocturnal dyspnea, peripheral edema, orthopnea, breathlessness on exertion, angina on exertion.[explainmedicine.com]
  • Chronic AR is typically asymptomatic for years followed by progressive exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea.[merckmanuals.com]
  • ., fever due to endocarditis , chest pain due to aortic dissection ) Chronic AR May be asymptomatic for up to decades despite progressive LV dilation Palpitations Symptoms of left heart failure Exertional dyspnea Angina Orthopnea Easy fatigability Syncope[amboss.com]
  • Orthopnea - dyspnea when supine. 3. PND - Paroxysmal Nocturnal Dyspnea. Why do you get Nocturnal Angina with Aortic regurgitation? 1.[quizlet.com]
  • Signs of acute left heart failure — including severe dyspnea, even at rest, orthopnea and PND — arise. Hypotension, flash pulmonary edema and shock can also occur.[healio.com]
Congestive Heart Failure
  • If congestive heart failure can be stabilized by a medical regimen, a course of antibiotic therapy can be administered and elective valve replacement can be performed.[ncbi.nlm.nih.gov]
  • Intractable congestive heart failure ensued about 2 weeks, 1 week, and a few days, respectively, after onset of infection.[ncbi.nlm.nih.gov]
  • The main one is congestive heart failure. Medicines may not be effective in treating tricuspid regurgitation. Diuretics, or water pills, can help relieve body swelling, or edema , that’s due to congestive heart failure.[webmd.com]
  • Once they occur, the aortic regurgitation symptoms are mostly from congestive heart failure. Left heart failure results in symptoms related to low cardiac output.[healio.com]
  • Moderate aortic regurgitation (regurgitated fraction more than 60% of stroke volume) is usually associated with some degree of congestive heart failure.[derangedphysiology.com]
Heart Disease
  • Bonow help you to apply all of the latest scientific knowledge and clinical strategies with Valvular Heart Disease , a companion to Braunwald’s Heart Disease.[books.google.com]
  • Diagnosis and Management of Adult Congenital Heart Disease, by Drs. Gatzoulis, Webb, and Daubeney, is a practical, one-stop resource designed to help you manage the unique challenges of treating long-term adult survivors of congenital heart disease.[books.google.com]
  • Stay on top of the latest advances in molecular imaging, intravascular ultrasound, cardiovascular regeneration and tissue engineering, device therapy for advanced heart failure, atrial fibrillation management, structural heart disease, Chagasic heart[books.google.com]
  • Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. ‎[books.google.com]
  • Diseases 561 Abnormalities of Right Ventricular Outflow 571 Infarction 446 Abnormal Vascular Connections and Structures 600 Suggested Readings 632 INDEX Masses Tumors and Source of Embolus 711 Echocardiography in Systemic Disease and Clinical Problem[books.google.com]
Chest Pain
  • In patients with chest pain and acute aortic regurgitation associated with flail aortic valve, localized intimal tear of aorta should be considered as a possible cause of flail aortic valve.[ncbi.nlm.nih.gov]
  • Consequently, patients may experience dyspnea, chest pain, and general body weakness. The onset of AAR features such as chest pain and dyspnea is sudden.[symptoma.com]
  • Symptoms may include chest pain or pressure, fainting, and shortness of breath. These are signs that you are likely to need surgery.[uofmhealth.org]
Heart Murmur
  • At CHOP's Cardiac Center, we usually diagnose aortic regurgitation after a primary care doctor detects a heart murmur and refers a child to us.[chop.edu]
  • A doctor usually diagnoses a leaky heart valve by: Listening to the heart with a stethoscope for abnormal sounds such as a heart murmur Looking at the results of a heart ultrasound , also called an echocardiogram A person’s description of symptoms along[webmd.com]
  • murmur that can be heard through a stethoscope Very forceful beating of the heart Bobbing of the head in time with the heartbeat Hard pulses in the arms and legs Low diastolic blood pressure Signs of fluid in the lungs Aortic regurgitation may be seen[medlineplus.gov]
  • Regurgitation results in turbulence and the generation of characteristic heart murmurs .[cvphysiology.com]
  • murmur Sensations of a rapid, fluttering heartbeat (palpitations) When to see a doctor Contact your doctor right away if signs and symptoms of aortic valve regurgitation develop.[mayoclinic.org]
Diastolic Murmur
  • Early closure of the mitral valve, weak first heart sound, tall A wave of apexcardiogram, and early diastolic murmur indicated acute aortic regurgitation.[ncbi.nlm.nih.gov]
  • A 65-year-old man with chronic hypertension developed dyspnea, a cough, and a new diastolic murmur. Two-dimensional echocardiography showed severe aortic regurgitation. No valvular vegetations were identified and blood cultures were negative.[ncbi.nlm.nih.gov]
  • Murmur in acute AR Soft EDM (early diastolic murmur) is heard in acute AR. It is due to low cardiac output.There is decreased pressure gradient between aorta and left ventricle due to elevated LVEDP.[notes.medicosnotes.com]
  • Subsequent clinical progress was slow, and the patient developed a pronounced aortic diastolic murmur that was not present on admission.[revespcardiol.org]
  • S 1 is soft; S 2 is obscured by a soft regurgitant murmur and a louder, low-pitched, late-diastolic murmur.[merckmanuals.com]
Tachycardia
  • Pulse rate à Tachycardia 2. Increased chance for hypotension 3. There won’t be cardiomegaly 4.[notes.medicosnotes.com]
  • Signs of the disease commonly include tachycardia, cyanosis, pulsus alternans, crepitations in the lungs indicating pulmonary edema and hypotension and peripheral vasoconstriction leading to cool extremities.[symptoma.com]
  • System 613 Chapter35D Cardiac Manifestations of Selected Neurologic 626 Chapter35E Cardiovascular Manifestations of Rheumatic 638 Chapter35F The Heart and Infectious Diseases 656 Chapter36 Substance Abuse and the Heart 669 Chapter 63 961 Ventricular Tachycardia[books.google.com]
  • Diagnostic Testing ECG Tachycardia, LVH, and LAE (more common in chronic AR). New conduction block may suggest an aortic root abscess. CXR Look for pulmonary edema, widened mediastinum, and cardiomegaly.[unboundmedicine.com]
  • Physical findings in Chronic AR • Pulse • Rate is normal • Sinus tachycardia in patients with CHF • Collapsing( Corrigan’s or water hammer pulse) • Blood pressure • Low diastolic pressure • Wide pulse pressure 22.[slideshare.net]
Intracranial Hemorrhage
  • Surgical intervention was recommended, but the patient died of an acute intracranial hemorrhage two weeks later. At autopsy, the posterior aortic cusp was flail, due to rupture of the residual cord above two large fenestrations.[ncbi.nlm.nih.gov]

Workup

Acute aortic regurgitation is diagnosed clinically, combining history and physical examination findings.

Diagnostic imaging modalities include:

  • Transesophageal echocardiography (TEE), which is useful in diagnosing and assessing AAR and visualizing the cause of the defect.
  • Transthoracic echocardiogram (TTE) [6].
  • Doppler echocardiography (DE): This is a test used in observing and quantifying regurgitation through the aortic valve. It is the most preferred exam. With DE, it is also possible to assess the anatomy of the root of the aorta and left ventricle.
  • Computerized tomography (CT) and magnetic resonance imaging (MRI) have a role in the assessment, as they show the extent of involvement of the aorta. MRI can further provide information on left ventricular function and extent of AAR.
  • Radionuclide imaging determines the ejection fraction of the left ventricle.
  • Electrocardiogram: This may show electrical abnormalities as well as signs of chamber hypertrophy and enlargement. It is a test that is sensitive and specific (over 90% for both) and is used to aid the timing of surgical intervention [7].
  • Chest X-ray: This may show signs of heart failure, such as pulmonary edema.
  • Coronary angiography is important to search for coronary artery disease.

Biochemical studies may be chosen by the physician, according to the patient's clinical features and suspected etiology. These may include full blood count, blood culture, rheumatic makers, and specific organ function tests.

The severity of AAR can be determined by the vena contracta, measured via color Doppler [8] [9]. A value of more than 6mm indicates severe disease. This measurement is highly sensitive and specific.

Treatment

  • Recognition and treatment of the most usual causes of acute aortic regurgitation have been described and the emphasis placed on early surgical treatment in the appropriate patient.[ncbi.nlm.nih.gov]
  • One patient died suddenly from acute heart block while undergoing medical treatment.[ncbi.nlm.nih.gov]
  • Apply today's best medical and surgical approaches with comprehensive, expert guidance on today's full range of clinical heart disease treatments.[books.google.com]
  • Seite 24 - Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). ‎ Seite 134 - Sacks FM, Pfeffer MA, Moye LA et al.[books.google.com]
  • During the past decade the number of transcatheter aortic valve replacements (TAVRs) performed has increased dramatically, and TAVR is now an accepted treatment option for patients with severe aortic stenosis who are not surgical candidates or are at[ncbi.nlm.nih.gov]

Prognosis

  • Furthermore, its prognosis is much poor than the chronic form of the disease. The main symptoms of AAR are vascular and in keeping with cardiac failure. Consequently, patients may experience dyspnea, chest pain, and general body weakness.[symptoma.com]
  • Cardiología, Complejo Hospitalario Universitario de Huelva, Huelva, Spain c Servicio de Cirugía Cardiaca, Hospital Puerta del Mar, Cádiz, Spain Article To the Editor, Percutaneous coronary procedures are safe techniques that have greatly improved the prognosis[revespcardiol.org]
  • However, the prognosis for those with severe AR and HF is considerably poorer.[merckmanuals.com]
  • […] valvular regurge; aortic valvular regurge; Aortic Valvular Regurge; aortic regurgitation Overview Pathophysiology Causes Differentiating Aortic Insufficiency from other Diseases Epidemiology and Demographics Risk Factors Natural History, Complications and Prognosis[wikidoc.org]
  • […] squatting and handgrip Austin Flint murmur In more severe stages, possibly a harsh , crescendo-decrescendo mid-systolic murm u r that resembles the ejection murmur heard in aortic stenosis Screening tests (optional) References: [3] [4] [1] [2] Treatment Prognosis[amboss.com]

Etiology

  • It has a number of etiologies, including infective and iatrogenic ones. This condition is more common in males.[symptoma.com]
  • Difference between acute AR and chronic AR Acute AR etiology 2. Infective endocarditis Features of acute AR 1. Pulse rate à Tachycardia 2. Increased chance for hypotension 3. There won’t be cardiomegaly 4.[notes.medicosnotes.com]
  • Etiology AR can be caused by primary disease of the aortic valve leaflets or dilation of the aortic root.[online.epocrates.com]
  • Over the past 60 years, the etiology of most valvular heart diseases in industrialized countries shifted towards degenerative etiologies, mainly because of a decrease in acute rheumatic fever.[textbookofcardiology.org]
  • Regarding etiology, structural abnormalities, such as a bicuspid aortic valve or prolapse of the AV may be seen.[healio.com]

Epidemiology

  • […] aortic regurge; aotic regurgitation; aotic regurge; regurge; regurgitation; valvular regurge; aortic valvular regurge; Aortic Valvular Regurge; aortic regurgitation Overview Pathophysiology Causes Differentiating Aortic Insufficiency from other Diseases Epidemiology[wikidoc.org]
  • To understand the epidemiology, aetiology, pathophysiology and prognosis of aortic regurgitation 2. To review the qualitative and quantitative echocardiographic methods available to assess severity 3.[bsecho.org]
  • […] in the literature in association with AR or aortic valve endocarditis. [18] Connective tissue disorders that can cause significant AR include the following: Floppy aortic valve Aortic valve prolapse Sinus of Valsalva aneurysm Aortic annular fistula Epidemiology[emedicine.medscape.com]
  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
  • Epidemiology Valvular heart diseases are a major burden to society and it is expected that the prevalence will increase. Rheumatic valve disease used to be the most prevalent etiology of valvular cardiac diseases worldwide.[textbookofcardiology.org]
Sex distribution
Age distribution

Pathophysiology

  • Information relating to the pathophysiology and hemodynamics of acute AR and TAVR-related acute AR, respectively, are collated in this review.[ncbi.nlm.nih.gov]
  • Pathophysiology, clinical recognition and management . Ann Intern Med . 1977 ; 87 :223–232. Crossref Medline Google Scholar 3. Pridie RB, Benham R, Oakley CM . Echocardiography of the mitral valve in aortic valve disease .[circ.ahajournals.org]
  • 1243 Percutaneous Coronary Intervention 1258 Percutaneous Cardiac Procedures 1273 Coronary Artery Bypass Surgery 1290 Approaches to the Patient with Prior Bypass Surgery 1306 Percutaneous Valve Dilatations 1316 Global Pandemic of Heart Failure 1330 Pathophysiology[books.google.com]
  • The mechanisms of diastolic mitral regurgitation in patients with acute aortic regurgitation have been considered to be the summation of the following pathophysiology: reversed atrio-ventricular pressure gradient due to aortic regurgitation in the non-compliant[kjim.org]
  • Aortic Regurgitation Pathophysiology 8. Aortic Regurgitation Pathophysiology 9.[slideshare.net]

Prevention

  • Operative intervention earlier rather than later generally improves results and prevents the long-term complications of delayed operations in anatomically complex patients.[ncbi.nlm.nih.gov]
  • Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. ‎[books.google.com]
  • […] s implanted in the RCA ostium protruding into the aorta. 3 , 4 Of the very few reported cases of direct catheter perforation of the coronary leaflet, most involve intervention in the RCA with Amplatz catheters. 5 , 6 This type of complication can be prevented[revespcardiol.org]
  • The aortic valve has three flaps, called leaflets, which open to allow blood to enter the aorta and close to prevent blood from flowing backwards into the heart.[nyulangone.org]
  • Make sure it's well-controlled to prevent aortic regurgitation. Aug. 02, 2017[mayoclinic.org]

References

Article

  1. Obadia JF, Tatou E, David M. Aortic valve regurgitation caused by blunt chest injury. Br Heart J. 1995;74(5):545–547.
  2. Hamirani YS, Dietl CA, Voyles W, Peralta M, Begay D, Raizada V. Acute aortic regurgitation. Circulation. 2012;126(9):1121–1126.
  3. Stout KK, Verrier ED. Acute valvular regurgitation. Circulation. 2009;119(25):3232-3241.
  4. Bekeredjian R, Grayburn PA. Valvular heart disease: aortic regurgitation. Circulation. 2005;112(1):125-134.
  5. Babu AN, Kymes SM, Carpenter Fryer SM. Eponyms and the diagnosis of aortic regurgitation: what says the evidence? Ann Intern Med. 2003;138(9):736-742.
  6. Lancellotti P, Tribouilloy C, Hagendorff A, et al. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease). Eur J Echocardiogr. 2010;11(3):223-244.
  7. Nishimura RA, Otto CM, Bonow RO, et al. 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. 2014;129(23):2440-2492.
  8. Tribouilloy CM, Enriquez-Sarano M, Bailey KR, Seward JB, Tajik AJ. Assessment of severity of aortic regurgitation using the width of the vena contracta: a clinical color Doppler imaging study. Circulation. 2000;102(5):558-564.
  9. Willett DL, Hall SA, Jessen ME, Wait MA, Grayburn PA. Assessment of aortic regurgitation by transesophageal color Doppler imaging of the vena contracta: validation against an intraoperative aortic flow probe. J Am Coll Cardiol. 2001;37(5):1450-1455.

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Last updated: 2018-06-21 21:20