Aortic insufficiency prognosis


 * Associate Editor-in-Chief: Varun Kumar, M.B.B.S., Lakshmi Gopalakrishnan, M.B.B.S.

Overview
Chronic aortic insufficiency is usually insidious and progressive. Aortic insufficiency may be asymptomatic for years, symptoms such as angina, syncope, exercise intolerance and other symptoms appear once heart failure present. Its important to detect any change in heart function early in the course of the disease before functional deterioration. Surgery should be indicated in patients with decreased ventricular function or for those who have symptoms.

Natural History
Chronic aortic insufficiency progression in general is slow and insidious; it may remain asymptomatic for years or even decades especially in mild cases. More severe cases can present earlier due to heart failure symptoms; angina and syncope. The left ventricular function should be followed through the measurement of the ejection fraction and the left ventricular end-diastolic dimension to know if an intervention is required.

The prognosis and survival rate for symptomatic aortic regurgitation have been improved dramatically in the last decade; the five year survival rate for symptomatic patients is more than 80 percent.

Complications
Acute severe aortic insufficiency if left untreated can increase risk of morbidity and mortality by causing:
 * 1) Left ventricular dysfunction leading to hemodynamic compromise
 * 2) Infective endocarditis
 * 3) Aortic dissection

Chronic aortic insufficiency if untreated can lead to:
 * 1) Heart failure
 * 2) Arrhythmia
 * 3) Myocardial ischemia
 * 4) aortic dissection in patients with bicuspid aortic valve
 * 5) Infective endocarditis

Prognosis
Prognosis for patients with aortic insufficiency depends on symptoms and left venticular function.

In asymptomatic patients with normal ejection fraction
 * Rate of progression to symptoms or left ventricular dysfunction ≤ 6% per year
 * Rate of progression to asymptomatic left ventricular dysfunction ≤ 3.5% per year
 * Rate of sudden death ≤ 0.2% per year

In asymptomatic patients with decreased ejection fraction
 * Rate of progression to symptoms ≥ 25% per year

In symptomatic patients
 * Mortality rate ≥ 10% per year

Morbidity and Mortality
Mortality and morbidity in acute severe aortic insufficiency is high due to inability of ventricle to accommodate increased regurgitant volume. Increased left ventricular pressure leads to increase in left atrial and pulmonary pressure, thereby causing pulmonary edema. Decrease in ejection fraction also leads to reduced coronary perfusion resulting in myocardial ischemia and even sudden cardiac death. Early surgical intervention improves the prognosis in these patients.

Chronic aortic insufficiency has a comparatively slower and longer course when asymptomatic. However, the patients rapidly deteriorate once symptoms sets in. Therefore serial echocardiographic assessment of left ventricular function is warranted in asymptomatic patients for determining the need for surgery.

Patients with chronic severe aortic insufficiency who are managed conservatively :
 * Death from any cause - 4.7% per year
 * Congestive heart failure - 6.2% per year
 * Aortic valve surgery - 14.6% per year

Asymptomatic Patients:
 * Mortality rate - 2.8% per year

Symptomatic patients:
 * NYHA class I - 3.0% per year
 * NYHA class II - 6.3% per year
 * NYHA class III-IV - 24.6% per year