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Aortic Valve Insufficiency

Aortic Regurgitation

Aortic valve insufficiency, also referred to as aortic regurgitation in cardiology guidelines and scientific literature, represents the incompetence of the aortic valve, causing diastolic flow from the aorta to the left ventricle, due to rheumatic valvular abnormalities, calcification, endocarditis, congenital bicuspid aortic valve, aortic dilatation or dissection and connective tissue diseases. Not only the aortic valve may be influenced by the pathological process, but also the leaflets, annulus and the ascending aorta, leading to the same result.


Presentation

Presentation depends on whether the valvular insufficiency is an acute or a chronic process.

Patients with acute aortic insufficiency have severe dyspnea, signs of cardiogenic shock (tachycardia, hypotension), cyanosis, pulmonary edema, acute heart failure (fatigability and peripheral edema) and chest pain if coronary or aortic dissection is the cause of the regurgitation [1].

Chronic aortic insufficiency leads to palpitations and dyspnea which is initially exertional and afterward occurs with minimal efforts and chest pain if coronary perfusion is compromised. As the disease progresses, orthopnea and paroxysmal nocturnal dyspnea start to occur. Angina is predominantly nocturnal in these patients. As with all valvular diseases, aortic insufficiency is prone to endocarditis, manifesting as fever and central or peripheral embolism.

Auscultation reveals single S1 and S2 sounds and a diastolic descrescendo, high-pitched murmur that increases with squatting. Systolic blood pressure tends to increase, while the diastolic component is prone to decrease.

Chronic aortic insufficiency, but not the acute form, is accompanied by several peripheral signs, reflecting increased stroke volume and wide pulse pressure: pulsation of the liver (Rosenbach), spleen (Gerhardt), retinal arterioles (Becker), cervix (Shelly), uvula (De Musset), capillaries of the nail bed (Quincke), systolic contraction and diastolic dilation of the pupil (Landolfi). In aortic insufficiency, auscultation of the femoral artery reveals systolic and diastolic sounds (Traube) and bruits if the artery is slightly compressed (Duroziez). The "water-hammer" pulse is known as Corrigan's sign, while De Musset's sign describes a specific bobbing motion of the head with each cardiac cycle. When popliteal blood pressure is at least 60 mm Hg higher than the brachial one, Hill's sign is present and if diastolic brachial pressure decreases by at least 15 mm Hg when the arm is raised above the head, Mayne's sign should be noticed. As symptoms worsen, so does the prognosis [2].

Dyspnea
  • (common) Orthopnea (common) Paroxysmal nocturnal dyspnea (common) Angina pectoris (less common) Abdominal discomfort (less common) Syncope (rare) Nocturnal angina with diaphoresis (rare) Causes of symptoms in chronic severe aortic valve insufficiency[emedicine.medscape.com]
  • Over time, heart failure symptoms manifest: exertional dyspnea, orthopnea and paroxysmal nocturnal dyspnea. Eventually, patients experience dyspnea at rest, reflecting severe decompensated heart failure.[clinicaladvisor.com]
  • When the legs are elevated at night, the fluid redistributes centrally, causing pulmonary edema that results in orthopnea (dyspnea while lying flat) or paroxysmal nocturnal dyspnea.[healio.com]
  • Syncope, dyspnea, or arrhythmia , as well as angina pectoris and a sudden death, can be the symptoms, but compared to the aortic stenosis, this occurs only rarely.[lecturio.com]
Orthopnea
  • 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]
  • The patient may experience dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and fatigue. Patient care A history of related cardiac illnesses and symptoms is obtained. Fever and other signs of infection are noted.[medical-dictionary.thefreedictionary.com]
  • […] gradual increase of stroke volume in most cases No symptoms for many years in most patients with chronic aortic valve insufficiency No symptoms for decades in most patients with chronic moderate aortic valve insufficiency Exertional dyspnea (common) Orthopnea[emedicine.medscape.com]
  • Over time, heart failure symptoms manifest: exertional dyspnea, orthopnea and paroxysmal nocturnal dyspnea. Eventually, patients experience dyspnea at rest, reflecting severe decompensated heart failure.[clinicaladvisor.com]
Exertional Dyspnea
  • […] the ascending aorta Catheter balloon valvuloplasty Trauma Chronic : Etiology Rheumatic fever Marfan's syndrome Hypertension Bicuspid aortic valve Membranous ventricular septal defect Ascending aortic aneurysm Aortic valve prolapse Signs and Symptoms Exertional[echocardiology.org]
  • […] the left ventricle (LV) and gradual increase of stroke volume in most cases No symptoms for many years in most patients with chronic aortic valve insufficiency No symptoms for decades in most patients with chronic moderate aortic valve insufficiency Exertional[emedicine.medscape.com]
  • Case presentation Case 1 A 58-year-old Chinese man was admitted to our department with chief complaint of exertional dyspnea for one month. His past medical history was unremarkable.[cardiothoracicsurgery.biomedcentral.com]
  • Over time, heart failure symptoms manifest: exertional dyspnea, orthopnea and paroxysmal nocturnal dyspnea. Eventually, patients experience dyspnea at rest, reflecting severe decompensated heart failure.[clinicaladvisor.com]
Fatigue
  • See your doctor if you have fatigue, shortness of breath, and swollen ankles and feet, which are common symptoms of heart failure. Causes Your heart has four valves that keep blood flowing in the correct direction.[mayoclinic.org]
  • Other symptoms may include fatigue, shortness of breath, or heavy or rapid breathing, especially during exercise.[uwhealth.org]
  • If your heart isn't working efficiently, you may feel aortic regurgitation symptoms including fatigue and short of breath. Aortic regurgitation can develop suddenly or over decades. It has a variety of causes, such as rheumatic fever or infection.[heart-valve-surgery.com]
Congestive Heart Failure
  • The left ventricle may begin to enlarge and dilate, which can lead to congestive heart failure. Some patients may also develop an abnormal heartbeat (arrhythmia).[uwhealth.org]
  • 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]
  • When the heart cannot pump enough oxygenated blood to the body, congestive heart failure occurs.[jrcinsurancegroup.com]
  • When the heart begins to wear out, patients will experience symptoms of congestive heart failure. Patients that have been diagnosed with Aortic Valve Insufficiency must have regular, careful follow up appointments with a cardiologist.[heartsurgeryinfo.com]
Weakness
  • However, as aortic valve regurgitation worsens, signs and symptoms may include: Fatigue and weakness, especially when you increase your activity level Shortness of breath with exercise or when you lie down Swollen ankles and feet Chest pain (angina),[mayoclinic.org]
  • […] increases with exercise and goes away with rest Fainting Fatigue Palpitations (sensation of the heart beating) Shortness of breath with activity or when lying down Swelling of the feet, legs or abdomen Uneven, rapid, racing, pounding or fluttering pulse Weakness[wexnermedical.osu.edu]
  • As the damage progresses, the symptoms can appear suddenly, including: chest pain or tightness that increases with exercise and subsides when you’re at rest fatigue heart palpitations shortness of breath difficulty breathing when lying down weakness fainting[healthline.com]
Reiter's Syndrome
  • Causes of aortic insufficiency may include: Ankylosing spondylitis Aortic dissection Congenital (present at birth) valve problems, such as bicuspid valve Endocarditis High blood pressure Marfan syndrome Reiter syndrome (also known as reactive arthritis[wexnermedical.osu.edu]
  • These include: Ankylosing spondylitis Aortic dissection Congenital (present at birth) valve problems, such as bicuspid valve Endocarditis (infection of the heart valves) High blood pressure Marfan syndrome Reiter syndrome (also known as reactive arthritis[medlineplus.gov]
Chest Discomfort
  • A 58-year-old man who underwent AVR with mechanical valve due to severe aortic regurgitation secondary to BAV 7 years previously presented with exertional chest discomfort for 1 year.[ncbi.nlm.nih.gov]
  • discomfort Dyspnea Hypotension Uncomfortable awareness of heartbeat/palpitations Chest pain Sudden cardiovascular collapse Cause of symptoms in acute severe aortic valve insufficiency Sudden drop in coronary driving pressure Increased filling pressure[emedicine.medscape.com]
  • They are manifested as chest discomfort, dyspnea, and hypotension. Epidemiology Frequency United States An estimated 5 million Americans have at least one form of heart valve disease.[emedicine.medscape.com]
Abdominal Pain
  • Hepatic congestion can also occur, producing right upper quadrant abdominal pain. Palpitations may result from the large stroke volumes and forceful LV contractions.[healio.com]
Pulsatile Liver
  • liver) Gerhardt's sign (enlarged spleen) Duroziez's sign (systolic and diastolic murmurs heard over the femoral artery when it is gradually compressed) Hill's sign (A 20 mmHg difference in popliteal and brachial systolic cuff pressures, seen in chronic[doctorslounge.com]
Heart Disease
  • .); and Center for Structural Heart Disease, Henry Ford Health System, Detroit, MI (M.G., W.W.O.). Originally published 1 Oct 2014 Circulation: Cardiovascular Interventions. 2014;7:723–725[circinterventions.ahajournals.org]
  • A young woman with aortic valve insufficiency secondary to rheumatic heart disease underwent replacement of her diseased aortic valve with her own pulmonary valve and replacement of her pulmonary valve with an aortic cadaver homograft, the Ross procedure[ncbi.nlm.nih.gov]
  • ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease. Executive Summary.[emedicine.medscape.com]
  • Stenosis - when the valve doesn't open enough and blocks blood flow Valve problems can be present at birth or caused by infections, heart attacks, or heart disease or damage.[icdlist.com]
  • Some older adults in the United States were exposed to rheumatic fever as children, although they may not have developed rheumatic heart disease. Other diseases.[mayoclinic.org]
Chest Pain
  • Symptoms may include chest pain or pressure, fainting, and shortness of breath. These are signs that you are likely to need surgery.[northshore.org]
  • People with more severe aortic regurgitation may notice heart palpitations, chest pain, fatigue, or shortness of breath. Other symptoms include difficulty breathing when lying down, weakness, fainting, or swollen ankles and feet.[heart.org]
  • You have aortic insufficiency and your symptoms worsen or new symptoms develop (especially chest pain, difficulty breathing , or swelling ). Blood pressure control is very important if you are at risk for aortic regurgitation.[medlineplus.gov]
Palpitations
  • People with more severe aortic regurgitation may notice heart palpitations, chest pain, fatigue, or shortness of breath. Other symptoms include difficulty breathing when lying down, weakness, fainting, or swollen ankles and feet.[heart.org]
  • […] history of aortic insufficiency High blood pressure Use of drugs such as weight loss and appetite suppressant medications Symptoms of aortic insufficiency include: Shortness of breath with activity Exercise intolerance Lightheadedness Chest pain Heart palpitations[health.cvs.com]
  • […] with exercise or when you lie down Swollen ankles and feet Chest pain (angina), discomfort or tightness, often increasing during exercise Lightheadedness or fainting Irregular pulse (arrhythmia) Heart murmur Sensations of a rapid, fluttering heartbeat (palpitations[mayoclinic.org]
  • […] pulse Chest pain, angina type (rare) Under the chest bone; pain may move to other areas of the body, most often the left side of the chest Crushing, squeezing, pressure, tightness Pain increases with exercise and goes away with rest Fainting Fatigue Palpitations[wexnermedical.osu.edu]
Heart Murmur
  • The main sign of heart valve disease is an unusual heartbeat sound called a heart murmur. Your doctor can hear a heart murmur with a stethoscope. But many people have heart murmurs without having a problem.[icdlist.com]
  • 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]
  • Tagged as: AI , aortic insufficiency , aortic murmurs , aortic regurgitation , aortic valve regurgitation , AR , heart murmurs[highrisklifeinsuranceagency.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]
Hypertension
  • Moderate or severe tricuspid regurgitation may result from pulmonary hypertension . Pulmonary hypertension is high blood pressure in the pulmonary artery . This high blood pressure has many possible causes. The main one is congestive heart failure.[webmd.com]
  • These patients were older and more likely to have hypertension and baseline proximal thoracic aorta dilation.[ncbi.nlm.nih.gov]
  • Occasionally aortic insufficiency may be a result of bacterial endocarditis, dilatation of the aortic valve ring, hypertension and aortic arteriosclerosis, dissecting aortic aneurysm or trauma.[annals.org]
  • hypertension; vascular sclerosis due to maternal diabetes or collagen disease; or intrauterine infection.[medical-dictionary.thefreedictionary.com]
  • Patients with AR and hypertension should be treated with vasodilators such as a dihidropyridine calcium channel blocker or angiotensin converting enzyme (ACE) inhibitor.[clinicaladvisor.com]

Workup

Blood workup in aortic valve insufficiency should include complete blood count, inflammatory markers, and cultures if endocarditis is suspected, coagulation parameters like prothrombin time and activated partial thromboplastin time, electrolyte panel, renal and hepatic tests and lactate dehydrogenase.

Echocardiography is a valuable and accurate tool in aortic insufficiency, allowing morphological valvular description, vegetation identification, and ascending aorta evaluation for dissection or aneurysm. Cavity dimensions and ejection fraction should be evaluated, especially if surgical intervention is needed [3].

Severe aortic valvular insufficiency is defined by certain parameters, derived from color, continuous and pulsed wave Doppler studies: vena contracta > 6 mm, regurgitant volume > 60 mL/beat, regurgitation fraction > 50%, and holodiastolic flow reversal in the descending aorta. Left ventricle dilation and ejection fraction should also be investigated, as well as pulmonary hypertension, pericardial effusion and aortic dissection [4]. Transesophageal echocardiography is especially useful in patients with poor acoustic windows or valvular calcification which makes it difficult to identify valve anatomy. An enlarged aorta may need additional characterization using computer tomography [5] or magnetic resonance imaging [6], while radionuclide imaging may be useful in further investigating left ventricular ejection fraction if echocardiography results are disproportional to clinical status.

Electrocardiography can show cavity enlargement or hypertrophy or ischemia, while chest radiography shows cardiac dilatation with valvular insufficiency is chronic and a cardiac normal size if the problem is acute in character. In addition, X-ray helps to detect pulmonary edema.

Exercise testing is indicated in order to assess functional capacity of the heart in chronic aortic regurgitation [7].

Aortic angiography is indicated if dissection is suspected while coronary angiography is performed in all patients scheduled to undergo aortic valvular replacement, in order to assess the need for a concomitant coronary bypass [8].

Treatment

  • The surgery was canceled and the patient was maintained in a conservative treatment and discharged.[ncbi.nlm.nih.gov]
  • Treatment algorithms for de novo, post-LVAD AI have not been well defined. In the present report, we have described 6 patients who underwent aortic valve surgery for new-onset post-LVAD AI.[ncbi.nlm.nih.gov]
  • Treatment can be conservative, as well as surgical.[bookinghealth.com]
  • Transfemoral aortic valve implantation (TAVI) for the treatment of pure native aortic insufficiency is not routine clinical practice.[ncbi.nlm.nih.gov]
  • The outcome is generally poor if there is no treatment but is good with available modern treatments.[patient.co.uk]

Prognosis

  • Despite surgical therapy, patients with anuloaortic ectasia have a worse prognosis than those with aortic valve insufficiency.[ncbi.nlm.nih.gov]
  • The outlook (prognosis) is good if the valve is treated before the heart becomes badly damaged. What is the outcome? The outcome (prognosis) will depend on the underlying cause and the severity of aortic regurgitation.[patient.co.uk]
  • Prognosis [ 2 ] Patients with acute severe AR have a poor prognosis without intervention, due to their haemodynamic instability. Patients with chronic severe AR and symptoms also have a poor long-term prognosis.[patient.info]
  • Prognosis is very poor and natural history extremely short. Cardiac decompensation, dissection, and rupture are the most common complications (1).[link.springer.com]

Etiology

  • Acute : Etiology Infective endocarditis Dissection of the ascending aorta Catheter balloon valvuloplasty Trauma Chronic : Etiology Rheumatic fever Marfan's syndrome Hypertension Bicuspid aortic valve Membranous ventricular septal defect Ascending aortic[echocardiology.org]
  • Regarding etiology, structural abnormalities, such as a bicuspid aortic valve or prolapse of the AV may be seen.[healio.com]
  • The etiologies of chronic AR include connective tissue diseases such as Marfan syndrome and Ehlers-Danlos syndrome, bicuspid aortic valve, and other inflammatory diseases of the aorta.[openanesthesia.org]
  • Etiology of Aortic Insufficiency Image : „Phonocardiograms from Normal and Abnormal Heart Sounds” by Madhero88.[lecturio.com]

Epidemiology

  • In this article arrow-down Epidemiology arrow-down Presentation arrow-down Investigations arrow-down Management arrow-down Prognosis Synonyms: aortic insufficiency, aortic incompetence Aortic regurgitation (AR) may be caused by either problems with the[patient.info]
  • […] 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]
  • Epidemiology Incidence Aortic insufficiency affects approximately 5 out of every 10,000 people. Gender Generally more common in men Age It is most common in men between the ages of 30 and 60.[doctorslounge.com]
  • Epidemiology Frequency United States An estimated 5 million Americans have at least one form of heart valve disease. In 2000, 1 million Americans were affected by congenital heart disease. This is a 3-fold increase from 300,000 in 1980.[emedicine.medscape.com]
Sex distribution
Age distribution

Pathophysiology

  • Pathophysiology of Aortic Insufficiency Changes due to aortic insufficiency Due to the constant backflow of blood into the left ventricle, the volume load rises.[lecturio.com]
  • (See Pathophysiology and Etiology .)[emedicine.medscape.com]
  • Pathophysiologically, the left ventricle must continue to eject a large stroke volume to keep forward stroke volume normal.[aafp.org]
  • Pathophysiology – Aortic Regurgitation The abnormal backflow of blood that occurs leads to pathologic changes that are highly dependent on aortic regurgitation severity and pace of disease development.[healio.com]

Prevention

  • Based on this analysis the preventive competence of some drugs with remodelling potential is postulated: vasodilators, growth hormone, thyroxin analogues and carnitinepalmitoyltransferase-1 inhibitors. (Ref. 36.)[ncbi.nlm.nih.gov]
  • Make sure it's well-controlled to prevent aortic regurgitation. Aug. 02, 2017[mayoclinic.org]
  • As AI can progress slowly without compromising the child's development, attempted surgical repair can safely be deferred in children less than 5 years of age with minimal valvular involvement unless careful medical management fails to prevent cardiac[ncbi.nlm.nih.gov]
  • Prevention and Self-care One possible way to prevent aortic valve regurgitation is to prevent rheumatic fever. Untreated strep throat can develop into rheumatic fever. Fortunately, strep throat is easily treated with antibiotics.[doctorslounge.com]
  • After each heartbeat, the valve closes tightly to prevent blood from flowing backwards into the heart. Aortic insufficiency occurs when the aortic valve does not close tightly enough.[health.cvs.com]

References

Article

  1. 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.
  2. Dujardin KS, Enriquez-Sarano M, Schaff HV, et al. Mortality and morbidity of aortic regurgitation in clinical practice. A long-term follow-up study. Circulation 1999;99:1851 – 1857.
  3. Friedman T, Mani A, Elefteriades JA. Bicuspid aortic valve: clinical approach and scientific review of a common clinical entity. Expert Rev Cardiovasc Ther. 2008;6(2):235-248.
  4. 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.
  5. Gaztanaga J, Pizarro G, Sanz J. Evaluation of cardiac valves using multidetector CT. Cardiol Clin. 2009;27(4):633-644.
  6. Morello A, Gelfand EV. Cardiovascular magnetic resonance imaging for valvular heart disease. Curr Heart Fail Rep. 2009;6(3):160-166
  7. Picano E, Pibarot P, Lancellotti P. The emerging role of exercise testing and stress echocardiography in valvular heart disease. J Am Coll Cardiol. 2009;54(24):2251-2260.
  8. [Guideline] 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):e521-643.

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Last updated: 2018-06-21 21:08