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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].

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]
Fatigue
  • Other symptoms may include fatigue, shortness of breath, or heavy or rapid breathing, especially during exercise.[uwhealth.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]
  • 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]
Weakness
  • However symptoms may include Tiredness Weakness Shortness of breath, especially with exercise or when you lie down Lightheadedness or fainting Swollen ankles ( oedema ) Treatment If the backflow of blood is mild then you may not need any treatment.[patient.info]
  • […] 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]
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[nlm.nih.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]
Dyspnea
  • As the disease progresses, orthopnea and paroxysmal nocturnal dyspnea start to occur. Angina is predominantly nocturnal in these patients.[symptoma.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]
  • (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]
  • Symptoms of aortic insufficiency are similar to those of heart failure and include the following: Dyspnea on exertion Orthopnea Paroxysmal nocturnal dyspnea Palpitations Angina pectoris Cyanosis (in acute cases) In terms of the cause of aortic insufficiency[en.wikipedia.org]
  • Among the 122 patients without dyspnea (class I), 9 had angina or syncope; therefore, 113 were strictly asymptomatic.[circ.ahajournals.org]
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]
Orthopnea
  • As the disease progresses, orthopnea and paroxysmal nocturnal dyspnea start to occur. Angina is predominantly nocturnal in these patients.[symptoma.com]
  • Symptoms of aortic insufficiency are similar to those of heart failure and include the following: Dyspnea on exertion Orthopnea Paroxysmal nocturnal dyspnea Palpitations Angina pectoris Cyanosis (in acute cases) In terms of the cause of aortic insufficiency[en.wikipedia.org]
  • […] 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]
Heart Disease
  • 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]
  • Aortic valve insufficiency can be due to, or associated with, congenital heart disease.[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]
  • Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Structural Heart Disease Keywords: Acute Kidney Injury, Aortic Valve Insufficiency[acc.org]
Chest Pain
  • 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.[symptoma.com]
  • 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]
  • Symptoms may include chest pain or pressure, fainting, and shortness of breath. These are signs that you are likely to need surgery.[northshore.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.[nlm.nih.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]
  • 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.[symptoma.com]
  • […] 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]
  • […] 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]
Hypertension
  • It is accompanied by systolic hypertension and wide pulse pressure, which account for peripheral physical findings, such as bounding pulses.[ncbi.nlm.nih.gov]
  • Some patients will incur myocardial structural changes, pulmonary hypertension, or arrhythmias before they manifest symptoms, with the risk that these adverse endpoints will not be reversible after valve repair or replacement.[ncbi.nlm.nih.gov]
  • 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]
  • 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]
  • Surgery is also reasonable (Class IIa) for patients who have pulmonary hypertension at rest or new-onset atrial fibrillation if they are candidates for mitral valve (MV) repair.[content.onlinejacc.org]
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]
  • Physical examination Echocardiography The diagnosis is based on the results of a physical examination (such as the collapsing pulse and characteristic heart murmur) and confirmed by echocardiography.[merckmanuals.com]
  • 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, more often with activity Signs may include: A heart[wexnermedical.osu.edu]
  • However, as the child grows older, symptoms begin to develop, and can include: Heart murmurs Fainting Chest pain Fatigue Aortic Valve Insufficiency Diagnosis A few tests or many tests are usually administered in order to diagnose aortic valve insufficiency[zofranlawsuitguide.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].

Left Ventricular Hypertrophy
  • ECG typically indicates left ventricular hypertrophy. Cardiac chamber catheterization assists in assessing the severity of regurgitation and any left ventricular dysfunction.[en.wikipedia.org]
  • Therefore, a chronic aortic valve insufficiency causes an isolated left ventricular hypertrophy . Initially, the cardiac output can be maintained and the patients remain asymptomatic.[lecturio.com]
  • ventricular hypertrophy Left atrial enlargement Chest X-ray Cardiomegaly (cor bovinum) Dilated aortic root Cardiac Catheterization Supravalvular angiography allows assessment of severity Quantification of Aortic insufficiency by Cardiac Catheterization[echocardiology.org]
  • Left ventricular hypertrophy, its dilatation (cavity expansion), signs of ischemia (insufficient blood supply) can be identified during this examination. Chest X-ray . The heart has the form of a "boot".[bookinghealth.com]
  • Different clinical signs such as a visible beating of the pulses at some sites and abnormals sounds heard over pulses (bruits) are characteristic of left ventricular hypertrophy.[healthhype.com]

Treatment

  • The outcome is generally poor if there is no treatment but is good with available modern treatments.[patient.info]
  • 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]
  • Analysis of determinants of survival with conservative treatment is essential to define high-risk groups that require aggressive treatment.[circ.ahajournals.org]

Prognosis

  • 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.info]
  • Despite surgical therapy, patients with anuloaortic ectasia have a worse prognosis than those with aortic valve insufficiency.[ncbi.nlm.nih.gov]
  • Patients diagnosed with severe aortic regurgitation in clinical practice incur excess mortality and high morbidity, underscoring the serious prognosis of the disease.[ncbi.nlm.nih.gov]
  • 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]

Etiology

  • Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology.[icd10coded.com]
  • 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]
  • 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]
  • (See Pathophysiology and Etiology .)[emedicine.medscape.com]

Epidemiology

  • […] 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]
Sex distribution
Age distribution

Pathophysiology

  • View this table: In this window In a new window Table 1 Aetiology of aortic regurgitation (AR) PATHOPHYSIOLOGY AND HAEMODYNAMIC CONSIDERATIONS AR causes volume overload of the left ventricle (LV).[doi.org]
  • 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]
  • (See Pathophysiology and Etiology .)[emedicine.medscape.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]
  • 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]
  • Future therapies may focus on molecular mechanisms to prevent adverse LV remodeling and fibrosis.[ncbi.nlm.nih.gov]
  • Moreover, commissuroplasty seems to prevent abnormal increase of the AV gradients.[ncbi.nlm.nih.gov]
  • 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