Aortic regurgitation for post graduates

MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI,
FCCP,FAPSC, FAPSIC, FAHA,FACP,FASE
Professor and Head of Cardiology
Colonel Malek Medical College , Manikganj.
For post-graduates
drtoufiq19711@yahoo.com16/8/2019
Post graduate version 2019

Case report
• A 53 years old gentleman presented with shortness
of breath on exertion for last 2 years , increasing in
intensity for last 3 months. On examination he is
dysnoeic, pulse-128/min, irregular, BP-100/30 mm
Hg, RR-32/min, diastolic thrill in apex, mid-diastolic
murmur in apical area, early diastolic murmur in left
lower sternal area and systolic murmur in aortic
area. ECG- Atrial Fibrillation, CXR-P/A view-
Cardiomegaly, Echocardiogram-severe mitral
stenosis with Moderate AS with severe AR with
moderate pulmonary hypertension. Patient
underwent DVR and he is doing well.
8/18/2019
Col. Malek Medical College, Manikganj
drtoufiq19711@yahoo.com
2

Normal valve function
•Maintain forward flow and prevent
reversal of flow.
•Valves open and close in response to
pressure differences (gradients) between
cardiac chambers.
drtoufiq1971@gmail.com

Abnormal valve function
•Valve Stenosis
•Obstruction to valve flow during that phase of the
cardiac cycle when the valve is normally open.
•Hemodynamic hallmark -“pressure gradient”
•Valve Regurgitation, insufficiency, incompetence
•Inadequate valve closure → reverse flow of the blood,
back leakage
•Combined – a single valve can be both stenotic and
regurgitant; combinations of valve lesions can coexist
•Single disease process
•Different disease processes
•One valve lesion may cause another
•Certain combinations are particularly common(AS & MR,
MS & TR)

Essential questions in the evaluation of
patients for valvular intervention

Diagnosis
• History
• Physical examination
• ECG
• Chest x-ray
• Echocardiography
• Invasive evaluation, CT,
MRI

History
•Other known heart diseses
• Congenital heart disease,
bicuspid aortic valve
• Ischemic heart disease
• Rheumatic fever
• Hypertrophic/dilated
cardiomyopathy
• Aortic diseases –
Marfans,Ehlers-Danlos

History
• Generally: symptoms of heart failure
and low cardiac output
• Breathlessness
• Chest pain or dyscomfort
• Syncope
• Fatigue
• Peripheral or pulmonary oedema
• Palpitations

Physical examination
• MURMURS!!!
• Periferal oedema
• Lung crackles
• Elevated JVP
• Displaced apex beat,
irregular heart beat…
Hundreds of eponymous signs from past
millenium (↓importance in daily
routine, ↑importance for passing exam)

Heart murmurs
•Sounds produces by turbulent
blood flow (in valve diseseses,
artery stenosis, abnormal
chamber or AVcommunication)
•Localization,grade,
propagation, timing, quality

Heart murmurs
Intensity Description
Grade I/VI Barely audible
Grade II/VI Audible, but soft
Grade III/VI Easily audible
Grade IV/VI Easily audible, associated with a thrill
Grade V/VI Easily audible, associated with a thrill, and still audible with the
stethoscope onlylightly on the chest
Grade VI/VI Easily audible, associated with a thrill, and still audible with the
stethoscope off of the chest

ECG
• Not specific
• Findings might be caused or altered by other
concomitant heart disease (hypertensive heart
disease, ischemic heart disease)
• Left ventricular hypertrophy (aortic valve
disease)
• Left atrial enlargement (mainy MS, but any left
heart valve disease)
• Atrial fibrilation
• Bundle branch block
• Arrytmias (atrial fibrilation, ectopic beats)

Chest x-ray in valvular disease
• Different heart shapes in different valvular
heart diseses, ↓specificity, ↓significance
• Cardiomegaly, pulmonary congestion
• Widened mediastinum
• Valve calcifications, prosthetic valves

Echocardiography
• Mainstay of valve disease
diagnosis and follow-up
• Allows real-time measurement of
chamber and wall diameters,
ejection fraction assessment and
functional valve evaluation
• Easily avaiable and repeated
• Essential in acute valve disease
diagnosis
• No radiation harm
• Trans-esophageal echocardiography
avaiable for patients with poor
transthoracic sonographic window

Invasive evaluation, CT, MRI
• Methods usualy used for uncertain cases or repeat
cardiac surgery / percutaneous inteventions planning
• Angiography to assess regurgitation severity – direct
transcatheter contrast medium administration into
heart chambers – aortography, ventriculography
• Hemodynamic measurment – measuring of
intracardial pressures and gradients
• CT aortography – method of choice in aortic
dissection diagnosis
• CMRI – very precise evaluation of cardiac tissues and
function, but expensive, low avaiability, long
examination time

Echocardiographic criteria for the definition of
severe valve regurgitation: an integrative approach

Aortic regurgitation
• Causes
• Chronic aortic regurgitation
• Bicuspid aortic valve
• Rheumatic and degenerative – always with some
degree of stenosis
• Aortic root dilation (hypertension, Marfan’s,
Ehlers-Danlos, syphylitic aortopathy)
• Other rare causes (SLE, RA)
• Acute aortic regurgiation
• Infective endocarditis
• Aortic regurgitation

• Pathophysiology of chronic aortic regrgitation
• Leakage of blood into LV during diastole due
to ineffective coaptation of the aortic cusps
• Combined pressure and volume overload
• Compensatory Mechanisms: LV dilation, LVH.
Progressive dilation leads to heart failure
• Greatest mass of myocardium in any valve
disease – „cor bovinum“ – over 500g

• Presentation
• Dyspnea: exertional, orthopnea,
and paroxsymal nocturnal
dyspnea
• Chest pain
• Fatigue
• Palpitations: due to increased
force of contraction or arrythmias

•Physical findings (the ones you might find)
• Diastolic blowing murmur at the left sternal border –
might be very discrete. Systolic ejection murmur might
be present due to increased blood flow across the
aortic valve of concomitant valve stenosis
• Wide pulse pressure – caused by diastolic
regurgitation of blood to LV and fast decrease of
diastolic BP – „Corrigan’s pulse“ (160/30 mmHg…)
• Heaving and laterally displaced apex beat – due to
dilated heart with giant stroke volume

•Physical findings (the ones you might not find…)
• Quincke’s sign - pulsations of nail bed
• Muller’s sign - pulsation of uvula
• De Musset sign - (head nodding in time with
the heart beat)
• Duroziez sign (systolic and diastolic murmurs
heard over the femoral artery when it is
gradually compressed with the stethoscope)
• Austin Flint murmur (apex): Regurgitant jet
impinges on anterior MVL causing it to vibrate

Echocardiographic Evaluation
Assessment of valve morphology: tricuspid, bicuspid,
unicuspid or quadricuspid valve.
• Determination of the direction of the aortic regurgitation jet
in the long-axis view (central or eccentric) and its origin in the
short-axis view (central or commissural).
• Identification of the mechanism, following the same
principle as for mitral regurgitation: normal cusps but
insufficient coaptation due to dilatation of the aortic root
with central jet (type 1), cusp prolapse with eccentric jet (type
2) or retraction with poor cusp tissue quality and large central
or eccentric jet (type 3).

• Quantification of aortic regurgitation should follow an
integrated approach considering all qualitative, semi-
quantitative and quantitative parameters.
• Measurement of LV function and dimensions. Indexing LV
diameters for body surface area (BSA) is recommended in
patients with small body size (BSA <1.68 m2).
• New parameters obtained by three-dimensional (3D)
echocardiography, tissue Doppler and strain rate imaging
may be useful, particularly in patients with borderline left
ventricular ejection fraction (LVEF), where they may help in
the decision for surgery.

• Measurement of the aortic root and ascending aorta in the 2-
dimensional (2D) mode at four levels: annulus, sinuses of
Valsalva, sinotubular junction and tubular ascending aorta.
Measurements are taken in the parasternal long-axis view from
leading edge to leading edge at end diastole, except for the aortic
annulus, which is measured in mid systole.
• As it will have surgical consequences, it is important to
differentiate three phenotypes of the ascending aorta: aortic
root aneurysms (sinuses of Valsalva >45mm), tubular ascending
aneurysm (sinuses of Valsalva <40– 45mm) and isolated aortic
regurgitation (all diameters <40mm). The calculation of
indexed values has been recommended to account for body
size.

• Definition of the anatomy of the aortic valve
cusps and assessment of valve reparability
should be provided by preoperative TOE if aortic
valve repair or a valve-sparing surgery of the
aortic root is considered.
• Intraoperative evaluation of the surgical result
by TOE is mandatory in patients in whom the
aortic valve is preserved or repaired in the
procedure.

• Acute aortic regurgitation
• Caused by a leaflet perforation in infective
endocarditis
• In aortic dissection due to a change in aortic root
geometry – dilation, extensive intimal tear with
prolapse into LVOT and coaptation impairment
• Presentation of acute aortic regurgitation itself is
usually a pulmonary oedema accompanied by
symptoms of the causing pathology
• True emergency – mostly requires immediate cardiac
surgery

Therapy –surgical
• Isolated leaflet pathology - aortic valve
replacement
• Aortic root pathology - combined aortic
root, ascendent aorta and aortic valve
replacement – Bentall’s procedure

Indication for replacement
• Severe aortic regurgitation (EROA – effective
regurgitant orifice area >0,3 cm2)
• Symptomatic
• LV dilates (over 50 mm EDD) or function
decreases (EF < 55%)
• Other indication for surgery
• Acute
• Moderate regurgitation (AVA 1,5-1 cm2 )
• With other indication for surgery

Target INR for mechanical prostheses

Recommended requirements of a heart valve Centre

The evaluation of aortic regurgitation requires consideration of
valve morphology and the mechanism and severity of regurgitation,
including careful assessment of aortic dilatation.
• In asymptomatic patients with severe aortic regurgitation, careful
follow-up of symptomatic status and LV size and function is
mandatory.
• The strongest indication for valve surgery is the presence of
symptoms (spontaneous or on exercise testing) and/or the
documentation of LVEF <50% and/or end-systolic diameter >50 mm.
• In patients with a dilated aorta, definition of the aortic pathology
and accurate measurements of aortic diameters are crucial to guide the
timing and type of surgery.
• Aortic valve repair and valve-sparing aortic surgery instead of
aortic valve replacement should be considered in selected cases in
experienced centres.

Aortic regurgitation for post graduates

More Related Content

What's hot

Similar to Aortic regurgitation for post graduates

More from PROFESSOR DR. MD. TOUFIQUR RAHMAN

Recently uploaded

Aortic regurgitation for post graduates