Transcript Valvular Heart Disease Aortic Regurgitation

Etiology
*Any conditions resulting in
incompetent aortic leaflets
_Acquired
* Rheumatic heart disease
_Congenital
Bicuspid AV
_Aortopathy
Cystic medial necrosis
Collagen disorders (.Marfan Syn.]
Ehler-Danlos
Osteogenesis imperfecta
Pseudoxanthoma elasticum
*Dilated aorta [ hyperte.]
*Degenerative
*Connective tissue disorder
_ Ankylosing spondylitis,
_Rheumatoid arthritis,
_Reiter’s syndrome,
_Giant-cell arteritis )
*Syphilis (chronic aortitis)
*Acute AR:
, _Infective endocarditis,
_Trauma
_Dissecting aneurysm
LVDOL…. LV dilatation …. Increased
SV ….. Wide PP…..LVH …Dilated LA
…. Increased LVEDP……LAP rise …..
Pulmonary congestion …. PH …. RVH
……RVF
Chronic AR
Elevated LV end-diastolic pressure and
volume
Dilatation and eccentric hypertrophy of
the LV
Increased stroke volume
Left ventricular EF  normal
Gradually LV preload and afterload
both increased
Ultimately, adaptive measures fail.
LV function deteriorates
End-diastolic volume rises further (the
largest heart)  Myocardial ischemia
Decline in forward stroke volume and
EF
Symptoms
Mild to moderate AR :
* Often
asymptomatic * Palpitation
Severe AR :
_Dyspnea, orthopnea, PND
_Chest pain.
Nocturnal angina >> exertional angina
{ diastolic aortic pressure and increased
LVEDP thus  coronary artery
diastolic flow}
*With extreme reductions in diastolic pressures
{e.g. < 40} may see angina
Peripheral Signs
_Quincke’s sign: capillary
pulsation
_Corrigan’s sign: _Water
hammer pulse
_Bisferiens pulse (AS/AR > AR)
_De Musset’s sign: systolic
head bobbing
_Mueller’s sign: systolic
pulsation of uvula
_Durosier’s sign: femoral
retrograde bruits
_Traube’s sign: pistol shot
femorals
_Hill’s sign:BP Lower
extremity >BP Upper
extremity by
_> 20 mm Hg - mild AR
_> 40 mm Hg – mod AR
_> 60 mm Hg – severe AR
Central Signs of Severe
Apex:
_Enlarged
_Displaced
_HyperdynamicLforcible
nonsustained
_Palpable S3
_Austin-Flint murmur
Aortic diastolic murmur
_Length correlates
with severity
{chronic AR}
_In acute AR murmur
shortens as
Aortic DP=LVEDP
_In acute AR - mitral
pre-closure
Physical examination
Widened pulse pressure
systolic – diastolic =
pulse pressure
_
AUSCULTATION
Murmur: high-pitched, blowing, decrescendo diastolic murmur, heard best in the third
intercostal space along the left sternal border (holodiastolic in severe AR)
When the murmur is soft, it can be heard best with the diapgm hraof the stethoscope and
with the patient sitting up, leaning forward, and with the breath held in forced expiration.
10
A mid-systolic ejection murmur frequently audible in isolated AR
Flint murmur, a soft, low-pitched, rumbling mid-diastolic murmur probably
produced by the diastolic displacement of the anterior leaflet of the mitral
valve by the AR stream not due to hemodynamically significant mitral
obstruction
11
Common Murmurs and Timing
,_Systolic Murmurs
_ Aortic stenosis
_ Mitral insufficiency
_Mitral valve prolapse
_Tricuspid insufficiency
Diastolic Murmurs
_Aortic insufficiency
_Mitral stenosis
S1
S2
S1
Investigations :
*ECG :-
LVH + T inversion
*Chest XR :- _ Cadiac dilatation _ Aortic dilatation
_ Pulmonary congestion
*ECHO :-
_Dilated LV
_ Hyperdynamic LV
_Fluttering AML
_ Doppler detects reflux
*Cardiac Catheterization :-
_Dilated LV
_ AR
_Dilated aortic root
Chest XR PA view
ECG
Assessing severity of AR
*Assess severity by impact on peripheral signs and LV
 peripheral signs =  severity
 LV =  severity
S3
Austin –Flint murmer
LVH
radiological cardiomegaly
Natural history :
*Asymptomatic
Normal LV function {--good prognosis}
%/Y
_Progression to symptoms or LV dysfunction
_Progression to asymptomatic LV dysfunction
_ 5-year survival
_Sudden
<0.2
death
<6
< 3.5
75%
Abnormal LV function
_Progression to cardiac symptoms
25
*Symptomatic {poor prognosis
_Mortality
>10%
TX: Medical  Surgery BEFORE LV dysfunction
Bonow RO, et al, JACC. 1998;32:1486.
Management :
* Medical :
_Vasodilator { ACEIs }
_ Diuretics for pulmonary congestion
_Prophylaxis against IE _Treatment of underline cause e.g.
IE , Syphilis
*Surgical :
_AV replacement Mechanical or Bioprosthesis
_Aortic root replacement for dilated A root , {e.g. Syphilis ,
Marfan`s syndrome , Dissecting aneurysm }
*EHO indications for AVR : _LVEDD >55 _EF > 55% _FS > 27%
Criteria for Aortic Valve Replacement in
Chronic Aortic Regurgitation
Symptoms 
Congestive heart failure.
Declining exercise tolerance on exercise testing.
Angina
Anatomy, regardless of symptoms: 
Left ventricular dysfunction: EF <50%
Progressive left ventricular dilation or decline in
EF on serial studies
Severe dilation (echo):
- Left ventricular diastolic dimension >75 mm
- Left ventricular systolic dimension >55 mm
-Aortic root dimension >50 mm