Aortic regurgitation natural history, complications and prognosis

Jump to: navigation, search
Siren.gif

Resident
Survival
Guide

Aortic Regurgitation Microchapters

Home

Patient Information

Overview

Historical Pesrpective

Pathophysiology

Causes

Stages

Differentiating Aortic Regurgitation from other Diseases

Epidemiology and Demographics

Risk Factors

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Cardiac Stress Test

Electrocardiogram

Chest X Ray

Echocardiography

Cardiac MRI

Treatment

Acute Aortic regurgitation

Medical Therapy
Surgery

Chronic Aortic regurgitation

Medical Therapy
Surgery

Precautions and Prophylaxis

Special Scenarios

Pregnancy
Elderly
Young Adults
End-stage Renal Disease

Case Studies

Case #1

Aortic regurgitation natural history, complications and prognosis On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Aortic regurgitation natural history, complications and prognosis

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Aortic regurgitation natural history, complications and prognosis

CDC on Aortic regurgitation natural history, complications and prognosis

Aortic regurgitation natural history, complications and prognosis in the news

Blogs on Aortic regurgitation natural history, complications and prognosis

Directions to Hospitals Treating Aortic regurgitation

Risk calculators and risk factors for Aortic regurgitation natural history, complications and prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S; Usama Talib, BSc, MD [2]

Overview

In acute aortic insufficiency symptoms of heart failure often develop acutely. Chronic aortic insufficiency is usually insidious and progressive and the patient may remain asymptomatic for years. Once left ventricular dilation and left ventricular failure occur, dyspnea on exertion and exercise intolerance begin to occur. Later symptoms such as angina, syncope, and other symptoms of heart failure are present.[1]

Natural History

Acute Aortic Insufficiency

In acute aortic insufficiency symptoms of heart failure such as pulmonary edema often develop acutely. Acute aortic insufficiency is often secondary to either trauma or infective endocarditis. While the heart can accommodate the changes of chronic aortic insufficiency over time, the acute changes of acute aortic insufficiency are not well accommodated by the left ventricle.

The rapid rise in left ventricular pressure causes the mitral valve to close earlier during diastole. This early closure fortunately prevents backwards flow of blood into the pulmonary vascular bed. The very high left ventricular end diastolic pressure often keeps the aortic diastolic pressure from falling too low and thus there is often not a wide pulse pressure. Indeed absence of a wide pulse pressure in the patient with acute aortic insufficiency should alert the clinician to potential failure of the left ventricle.[2]

Chronic Aortic Insufficiency

Chronic aortic insufficiency is usually insidious and progressive and the patient may remain asymptomatic for years. Once left ventricular dilation and left ventricular failure occur, dyspnea on exertion and exercise intolerance begin to occur. Later symptoms such as angina, syncope, and other symptoms of heart failure are present. The hemodynamic impact of aortic regurgitation causes progressive dilation and hypertrophy of the left ventricle. The mitral valve ring may also dilate which may lead in turn to mitral regurgitation. The left atrium may dilate as a result of the mitral regurgitation. It has been said that 'aortic regurgitation begets aortic regurgitation'. The high oscillatory shear associated with aortic regurgitation may lead to further dilation of the aorta, which in turn may lead to further aortic regurgitation.[1]

Volume overload associated with aortic regurgitation leads to left ventricular hypertrophy. The sarcomeres replicate in series and there is elongation of the myocytes and myocardial fibrils. As a result of this hypertrophy the ratio of the ventricular wall thickness to cavity radius remains normal and therefore wall stress is normal. In aortic regurgitation there is eccentric hypertrophy where as in aortic stenosis there is concentric hypertrophy where there is replication of the sarcomeres in parallel. Once wall thickening fails to keep up with the hemodynamic load, end systolic wall stress rises and at this point the left ventricle fails. The dramatic enlargement of the heart that is seen with aortic regurgitation is called cor bovinum. Over time the left ventricle will decompensate and there will be increasing interstitial fibrosis and a stiffening or a reduction in the compliance of the left ventricular wall. At this point the patient will experience a rise in the end diastolic pressure and volume. The first decline is seen with exercise and then the patient begins to have a reduction in forward output at rest. [3]

Patients with chronic aortic insufficiency may also develop myocardial ischemia. This is due to the fact that they have an increase in demand due to an increased thickness of the LV and also a reduction in the supply due to a lower perfusion pressure during diastole.[3]

Complications

Acute Aortic Insufficiency

The complications of Acute Aortic Insufficiency include[1][4]

  1. Left ventricular volume overload in a non-compliant left ventricle with acute left ventricular failure
  2. Pulmonary edema
  3. Sudden cardiac death

Chronic Aortic Insufficiency

The complications of Chronic Aortic Insufficiency include:[5][6][7]

  1. Heart failure
  2. Arrhythmia
  3. Myocardial ischemia
  4. Aortic dissection in patients with bicuspid aortic valve
  5. Infective endocarditis

Prognosis

The prognosis and survival of patients with symptomatic aortic regurgitation has improved significantly over the last decade. The five year survival rate for symptomatic patients is now more than 80 percent.

Acute Aortic Insufficiency

The prognosis among patients with aortic insufficiency is poor with a high mortality and morbidity due to the acute onset of left ventricular failure, pulmonary edema, or myocardial ischemia due to the abrupt rise in LV wall stress and sudden cardiac death.[4] Early surgical intervention improves the prognosis in these patients.[2]

Chronic Aortic Insufficiency

The prognosis of a patient with Chronic Aortic Insufficiency can be summarised as follows:[8]

Asymptomatic Patients

The prognosis of asymptotic patients with Aortic Stenosis can be summarised as follow:[1][9]

  • Mortality rate ≈ 2.8% per year
  • 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
  • Rate of progression to symptoms ≥ 25% per year

Symptomatic Patients

The prognosis of symptomatic Aortic Regurgitation patients includes:

Chronic Severe Aortic Insufficiency Managed Conservatively

The prognosis of the conservative management of Chronic Severe Aortic Insufficiency includes:[10]

References

  1. 1.0 1.1 1.2 1.3 Bonow RO, Lakatos E, Maron BJ, Epstein SE (1991). "Serial long-term assessment of the natural history of asymptomatic patients with chronic aortic regurgitation and normal left ventricular systolic function". Circulation. 84 (4): 1625–35. PMID 1914102.
  2. 2.0 2.1 Rhodes LA, Keane JF, Keane JP, Fellows KE, Jonas RA, Castaneda AR; et al. (1990). "Long follow-up (to 43 years) of ventricular septal defect with audible aortic regurgitation". Am J Cardiol. 66 (3): 340–5. PMID 2368680.
  3. 3.0 3.1 Olsen NT, Sogaard P, Larsson HB, Goetze JP, Jons C, Mogelvang R; et al. (2011). "Speckle-tracking echocardiography for predicting outcome in chronic aortic regurgitation during conservative management and after surgery". JACC Cardiovasc Imaging. 4 (3): 223–30. doi:10.1016/j.jcmg.2010.11.016. PMID 21414568.
  4. 4.0 4.1 Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines 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 (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Retrieved 2011-04-19. Unknown parameter |month= ignored (help)
  5. Pichard AD, Smith H, Holt J, Meller J, Gorlin R (1983). "Coronary vascular reserve in left ventricular hypertrophy secondary to chronic aortic regurgitation". Am J Cardiol. 51 (2): 315–20. PMID 6218741.
  6. Basta LL, Raines D, Najjar S, Kioschos JM (1975). "Clinical, haemodynamic, and coronary angiographic correlates of angina pectoris in patients with severe aortic valve disease". Br Heart J. 37 (2): 150–7. PMC 484095. PMID 804313.
  7. Bonow RO, Rosing DR, Maron BJ, McIntosh CL, Jones M, Bacharach SL; et al. (1984). "Reversal of left ventricular dysfunction after aortic valve replacement for chronic aortic regurgitation: influence of duration of preoperative left ventricular dysfunction". Circulation. 70 (4): 570–9. PMID 6478563.
  8. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA; et al. (2014). "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". J Am Coll Cardiol. 63 (22): e57–185. doi:10.1016/j.jacc.2014.02.536. PMID 24603191.
  9. Bonow RO, Rosing DR, McIntosh CL, Jones M, Maron BJ, Lan KK; et al. (1983). "The natural history of asymptomatic patients with aortic regurgitation and normal left ventricular function". Circulation. 68 (3): 509–17. PMID 6872164.
  10. Dujardin KS, Enriquez-Sarano M, Schaff HV, Bailey KR, Seward JB, Tajik AJ (1999). "Mortality and morbidity of aortic regurgitation in clinical practice. A long-term follow-up study". Circulation. 99 (14): 1851–7. PMID 10199882. Retrieved 2011-04-19. Unknown parameter |month= ignored (help)


Cardiology


Linked-in.jpg