Aortic regurgitation resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Aortic Regurgitation Resident Survival Guide Microchapters
Overview
Causes
FIRE
Diagnosis
Acute
Chronic
Treatment
Acute
Chronic
Type of Valve and Anticoagulation
Do's
Don'ts

Overview

Aortic regurgitation (AR) refers to the retrograde or backward flow of blood from the aorta into the left ventricle during diastole. The clinical presentation depends on the response and adaptability of the left ventricle to the increased left ventricular diastolic volume. In chronic AR, the left ventricle has adapted by dilatation of its walls; however, in acute AR a rapid increase in the diastolic volume is not tolerated by a normal-size ventricle which could lead to cardiogenic shock. Acute AR can be caused by either aortic dissection or infective endocarditis, and it requires immediate surgical intervention. The most common causes of chronic AR are bicuspid aortic valve and calcific valve disease. The treatment of chronic AR depends on the stage of the disease. Acute AR is a life-threatening condition and must be recognized and treated promptly.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Click here for the complete list of causes.

FIRE: Focused Initial Rapid Evaluation

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention. The algorithm below is based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease.[2][3]

Boxes in red signify that an urgent management is needed.

Abbreviations: ECG: Electrocardiogram; ICU: Intensive care unit; MAP: Mean arterial pressure ; P2: Second heart sound, pulmonary component; S1: First heart sound; S3: Third heart sound; TTE: Transthoracic echocardiography; TEE: Transesophageal echocardiography

 
 
 
 
 
 
Identify cardinal findings that increase the pretest probability of aortic regurgitation

Acute aortic regurgitation
❑ Low pitched early diastolic murmur
❑ Best heard at the right 2nd intercostal space

❑ Decreased or absent S1
❑ Increased P2
❑ Sudden onset of dyspnea



Chronic aortic regurgitation
❑ High pitched holodiastolic decrescendo murmur

❑ Best heard at the upper left sternal border
❑ Increases with sitting forward, expiration and handgrip
Wide pulse pressure (≥ 60 mmHg)
❑ Presence of S3
Corrigan's pulse: a rapid upstroke and collapse of the carotid artery pulse
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have any findings of cardiogenic shock that require urgent management?
Tachycardia
Hypotension
Altered mental status
Tachypnea
Oliguria
Cold extremities
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
 
 
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed to the complete diagnostic approach below
 
 
 
 
 
 
Initiate resuscitation measures:
❑ Secure airway
❑ Administer oxygen
❑ Secure wide bore IV access
❑ Perform ECG monitor
❑ Monitor vitals continuously
❑ Admit to ICU

Initiate medical therapy to treat cardiogenic shock:
❑ Administer nitroprusside 0.3-0.5 υg/kg/min IV (max 10 υg/kg/min), AND
❑ Administer dobutamine 0.5 υg/kg/min IV (max 20 υg/kg/min)
❑ Titrate to maintain MAP > 60 mmHg
❑ Administer beta blockers in high suspicion of aortic dissection
Do not use beta blockers for other causes as they will block the compensatory tachycardia

Order urgent TTE:
❑ Confirm aortic regurgitation
❑ Look for additional findings according to etiology:

Vegetations on the leaflets
Aortic root dissection
In high suspicion of aortic dissection or when TTE is nondiagnostic, perform a TEE

Do not perform percutaneous aortic balloon counterpulsation (it will increase the diastolic pressure and the regurgitant volume)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
What is the etiology of aortic regurgitation based on clinical findings and echocardiography?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Diagnostic clues:
Chest pain of the following characteristics:
❑ Sudden onset
❑ Intense
❑ Tearing and sharp
❑ Worsened by deep breathing or cough
❑ Relieved by sitting upright

❑ Unexplained syncope
❑ Low pitched early diastolic murmur

❑ Best heard at the right 2nd intercostal space

❑ Aortic root dissection found on TTE
❑ Previous history of:

Marfan syndrome
Connective tissue disorder
 


Diagnostic clues:
❑ Persistent fever
❑ New valvular regurgitation murmur
❑ Previous blood culture positive
Vegetations found on TTE
❑ High risk factors:
❑ Pre-existing cardiac abnormality
Prosthetic valve
❑ Recent surgical or medical procedures
Intravenous drug use
❑ Recent bacterial infection
❑ History of previous endocarditis


❑ Order blood cultures (if they have not been previously ordered)
❑ Evaluate the modified Duke criteria (click here to see)
 
Symptomatic severe chronic AR



Diagnostic clues:
❑ No TTE findings of aortic dissection or leaflet vegetations
❑ Previous history of aortic valve disease
❑ High pitched holodiastolic decrescendo murmur
❑ Best heard at the upper left sternal border
❑ Increases with sitting forward, expiration and handgrip
Wide pulse pressure (≥ 60 mmHg)
S3
Corrigan's pulse: a rapid upstroke and collapse of the carotid artery pulse

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Immediate surgical intervention
 
Immediate surgical intervention
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Proceed to the complete diagnostic approach below
 
 
 
 
 
 
 
 
 
 

Complete Diagnostic Approach

A complete diagnostic approach should be carried out after a focused initial rapid evaluation is conducted and following initiation of any urgent intervention.[2][3]

Abbreviations: AVR: Aortic valve replacement; BP: Blood pressure; CBC: Complete blood count; CXR: Chest X-ray; ECG: Electrocardiogram; ESR: Erythrocyte sedimentation rate; HF: Heart failure; LV: Left ventricle; LVEF: Left ventricle ejection fraction; MI: Myocardial infarction; S1: First heart sound; S2: Second heart sound; S3: Third heart sound; S4: Fourth heart sound; TTE: Transthoracic echocardiography; TEE: Transesophageal echocardiography; TAVR: Transcatheter aortic valve replacement

Acute Aortic Regurgitation

Shown below is a complete diagnostic approach for acute aortic regurgitation based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease.[2]

 
 
 
 
Characterize the symptoms:

❑ Sudden and severe dyspnea
Palpitations
Altered mental status
Cold extremities
Oliguria

Symptoms suggestive of aortic dissection
Chest pain

❑ Sudden onset
❑ Intense
❑ Tearing and sharp
❑ Interscapular
❑ Worsened by deep breathing or cough
❑ Relieved by sitting upright

❑ Unexplained syncope

Symptoms suggestive of infective endocarditis
Fever
Sweats
Fatigue
Pleuritic chest pain
Back pain
Weakness
Myalgias
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inquire about past medical history:
Suggestive of infective endocarditis

Bicuspid aortic valve
Rheumatic fever
Prosthetic valves
Intravenous drug use

❑ Substances used in the mixture
❑ Sharing the equipment
❑ The process of cleaning the equipment
❑ Previous infective endocarditis
Suggestive of aortic dissection
Hypertension
Marfan syndrome
Connective tissue disorder
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Vitals
Temperature

Fever (suggestive of infective endocarditis)

Heart rate

Tachycardia

Blood pressure

❑ Asymmetric blood pressure in the upper extremities
Hypertension (suggestive of aortic dissection)
Hypotension (suggestive of severe regurgitation or aortic dissection)

Respiratory rate

Tachypnea

Cardiovascular examination
❑ Weak pulses
Jugular venous distension
Cardiac auscultation

Murmur
❑ Low pitched early diastolic murmur (may be absent)
❑ Best heard at the right 2nd intercostal space in aortic dissection
Heart sounds
❑ Decreased or absent S1
❑ Increased P2 (suggestive of pulmonary hypertension)
S3 and S4 may be present

❑ Apical diastolic rumble
Respiratory examination
Rales (suggestive of pulmonary congestion)

Wheeze
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order labs and tests:

TTE (most important test) (Class I; Level of Evidence: B)

In high suspicion of aortic dissection, perform a TEE

Chest X-ray

❑ Increased cardiac silhouette (suggestive of aortic dissection)
Widened mediastinum (suggestive of aortic root dilation)
❑ Pulmonary congestion (suggestive of pulmonary edema or pulmonary hypertension)

ECG

❑ Nonspecific changes of ST and T wave (due to LV enlargement)
Right coronary artery ischemic changes (suggestive of aortic dissection)
ST elevation in II, III, aVF (inferior MI)
ST elevation in V3R and V4R (right ventricle MI)
ST depression in V1-V3 (posterior MI)

Blood culture (if suspected infective endocarditis)
CBC
ESR

Cardiac enzymes (Troponin, CK-MB)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Determine the etiology of the acute aortic regurgitation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 



Diagnostic clues:
Chest pain of the following characteristics:
❑ Sudden onset
❑ Intense
❑ Tearing and sharp
❑ Worsened by deep breathing or cough
❑ Relieved by sitting upright

Syncope
❑ Low pitched early diastolic murmur

❑ Best heard at the right 2nd intercostal space

❑ Previous history of:

Marfan syndrome
Connective tissue disorder

Click here for aortic dissection resident survival guide
 



Diagnostic clues:
❑ Persistent fever
❑ New valvular regurgitation murmur
❑ Positive blood culture
❑ Vegetations found on TTE
❑ High risk factors:
❑ Pre-existing cardiac abnormality
Prosthetic valve
❑ Recent surgical or medical procedures
Intravenous drug use
❑ Recent bacterial infection
❑ History of previous endocarditis
❑ Evaluate the modified Duke criteria (click here to see)

Click here for infective endocarditis resident survival guide
 
Other causes




 


Chronic Aortic Regurgitation

Shown below is a complete diagnostic approach for chronic aortic regurgitation based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease.[2]

 
 
 
 
 
 
Characterize the symptoms:
❑ Asymptomatic
Dyspnea on exertion
Orthopnea
Paroxysmal nocturnal dyspnea
Palpitations
Chest pain
Shortness of breath
Cough
Altered mental status
Syncope
Fatigue
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Vitals
Heart rate:

Tachycardia (suggestive of reduced stroke volume)

Blood pressure:

Wide pulse pressure (≥ 60 mmHg)

Cardiovascular examination
❑ Pulses

Corrigan's pulse: a rapid upstroke and collapse of the carotid artery pulse

Cardiac auscultation

Murmur
❑ High pitched holodiastolic decrescendo murmur
❑ Best heard at the upper left sternal border
Murmur increases with sitting forward, expiration and handgrip
Austin Flint murmur: a soft mid-diastolic rumble, best heard at the cardiac apex (suggestive of severe regurgitation)
Heart sounds
S2: decreased or absent A2; normal P2
S3 may be present (suggestive of left ventricular dysfunction)
S4 may also be present

❑ Search for other characteristic signs suggestive of aortic regurgitation

Traube's sign: 'pistol shot' pulse heard over the femoral artery
Müller's sign: systolic pulsations of uvula [4]
de Musset's sign: head bobbing with each heart beat
Hill's sign: ≥ 20 mmHg difference in popliteal and brachial systolic cuff pressures (suggestive of chronic severe AR)
Quincke's sign: pulsation of the capillary bed in the nail

Respiratory examination

Rales (seen when congestive heart failure has developed)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order imaging studies:

TTE (most important evaluation test) (Class I; Level of Evidence: B)
❑ CMR in cases of moderate or severe AR and suboptimal echocardiographic images for the evaluation of the severity of AR (Class I; Level of Evidence: B)
Chest X-ray

❑ Increased cardiac silhouette (suggestive of LV dilatation)
Widened mediastinum (suggestive of aortic root dilation)
Wide mediastinum.jpg
Pulmonary congestion (suggestive of HF)

ECG

❑ Nonspecific changes of ST and T wave (due to LV dilatation)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Classify aortic regurgitation based on the following findings on TTE:
Vena contracta
❑ Jet/LVOT
❑ Regurgitant volume
❑ Regurgitant fraction
❑ Effective regurgitant orifice
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ No regurgitation
 
Mild (Stage B)

Vena contracta <0.3 cm
❑ Jet/LVOT <25%
❑ Regurgitant volume <30 mL/beat
❑ Regurgitant fraction <30%
❑ Effective regurgitant orifice <0.10 cm²
 
Moderate (Stage B)

Vena contracta 0.3-0.6 cm
❑ Jet/LVOT 25-64%
❑ Regurgitant volume 30-59 mL/beat
❑ Regurgitant fraction 30-49%
❑ Effective regurgitant orifice 0.10-0.29 cm²
 
Severe

Vena contracta >0.6 cm
❑ Jet/LVOT ≥ 65%
❑ Regurgitant volume ≥60 mL/beat
❑ Regurgitant fraction ≥50%
❑ Effective regurgitant orifice ≥ 0.30 cm²
❑ Holodiastolic flow reversal in the proximal abdominal aorta
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the patient symptomatic?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Asses the LV and LVEF
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stage C1
❑ Normal LVEF
❑ Mild to moderate dilatation of LV
 
Stage C2
LV systolic dysfunction
❑ Decreased LVEF or severe LV dilatation
 
Stage D
❑ Normal or decreased LV systolic function
❑ Moderate to severe LV dilatation

Treatment

Abbreviations: AVR: Aortic valve replacement; ACE: Angiotensin converting enzyme; ARB: Angiotensin receptor blocker; CCB: Calcium channel blocker; LVEF: Left ventricle ejection fraction; TTE: Transthoracic echocardiography

Treatment of Acute Aortic Regurgitation

Shown below is an algorithm for the treatment of acute aortic regurgitation.[2]

 
 
 
 
What is the cause of acute AR?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Infective endocarditis
 
Aortic dissection
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have AR related heart failure symptoms?
 
❑ Schedule for an emergent surgery[5]
❑ Administer beta blockers with caution (beta blockers inhibit compensatory tachycardia)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Schedule for early aortic valve replacement (Class I, level of evidence B)[6]
Click here for more details
 
❑ Administer antibiotics[6]
❑ Follow up the patient
Click here for more details
 
 
 

Treatment of Chronic Aortic Regurgitation

Shown below is an algorithm depicting the indications for aortic valve replacement (AVR) in chronic aortic regurgitation. Patients that fulfill the indications for AVR but have existing comorbidities that do not permit AVR should be treated for hypertension if the blood pressure is more than 140 mmHg. Patients with stage A AR do not require any treatment.[2][3]

Abbreviations: LVEF: left ventricular ejection fraction; LVEDD: left ventricular end diastolic diameter; LVESV: left ventricular end systolic diameter

 
 
 
 
 
 
 
 
 
 
 
 
 
 
What is the severity of the aortic regurgitation?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Severe regurgitation

❑ Vena contracta >0.6 cm
❑ Doppler jet width ≥ 65% of LVOT
❑ Regurgitant volume ≥60 mL/beat
❑ Regurgitant fraction ≥50%
❑ Effective regurgitant orifice ≥ 0.30 cm²
❑ Holodiastolic flow reversal in the proximal abdominal aorta
Left ventricle dilatation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Progressive regurgitation (Stage B)

❑ Vena contracta <0.6 cm
❑ Regurgitant volume <60 mL/beat
❑ Regurgitant fraction <50%
❑ Effective regurgitant orifice <0.30 cm²
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the patient symptomatic?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Is the patient undergoing
another surgery?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
(Stage D)
 
 
 
 
 
 
 
 
 
No
(Stage C)
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ LVEF<50%
(Stage C2)
 
❑ The patient is undergoing another surgery
 
LVEF ≥ 50%
AND
❑ LVESD > 50mm
(Stage C2)
 
LVEF ≥ 50%
AND
❑ LVEDD > 65mm
AND
❑ Low surgical risk
 
LVEF ≥ 50%
AND
❑ LVESD ≤ 50mm
AND
❑ LVEDD ≤ 65mm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
AVR (Class I)
 
AVR (Class I)
 
AVR (Class I)
 
AVR (Class IIa)
 
AVR (Class IIb)
 
 
 
 
 
 
 
 
 
 
 
AVR (Class IIa)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Perform a periodic echocardiogram every 6 - 12 months (Class I, Level of Evidence C)
❑ Control hypertension preferably with
❑ Dihydropyridine CCB, or
ACE inhibitors or ARBs (Class I; Level of Evidence: B)
 

❑ Perform a periodic echocardiogram (Class I; Level of Evidence:B)

❑ Every 3 -5 years for mild regurgitation
❑ Every 1 - 2 years for moderate regurgitation

❑ Control hypertension preferably with

❑ Dihydropyridine CCB, or
ACE inhibitors or ARBs (Class I; Level of Evidence: B)

Type of Valve and Discharge Anticoagulation Therapy

Shown below is an algorithm depicting the factors that influence the choice of the type of the prosthetic valve and the discharge anticoagulation therapy.[2]

Abbreviations: AVR: Aortic valve replacement; INR: International normalized ratio; TAVR Tansthoracic aortic valve replacement

 
 
 
 
 
 
Determine:
Age
Contraindications for anticoagulation
❑ Major bleeding diathesis or coagulopathy
❑ Uncontrolled severe hypertension (systolic blood pressure >200 mmHg)
❑ Recent head trauma
❑ Platelet count < 100 000
Pregnancy
❑ Hypersensitivity to warfarin
Hemorrhagic stroke
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Patients ≤ 60 years old
AND
❑ No contraindication for anticoagulation (Class IIa; Level of Evidence: B)
 
❑ Patients 60 - 70 years old
AND
❑ No contraindication for anticoagulation
 
❑ Patients ≥ 70 years old (Class IIa; Level of Evidence: B)
OR
❑ Patients at any age AND contraindications for anticoagulation therapy (Class I; Level of Evidence: C)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bioprosthesic
OR
Mechanical prosthesis (Class IIa; Level of Evidence: B)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mechanical prosthesis
Avoid the use of direct thrombin inhibitors or anti-Xa agents in patients with mechanical prosthesis (Class III; Level of Evidence: B)
 
 
 
 
 
Bioprosthesis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Does the patient have risk factors for thromboembolism†?
 
 
 
 
 
Surgical AVR
OR
TAVR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
No
 
Surgical AVR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer for long term:
Warfarin to achieve INR of 3.0 (Class I; Level of Evidence: B)
AND
Aspirin 75-100 mg/d (Class I; Level of Evidence: A)
 
Administer for long term:
Warfarin to achieve INR of 2.5 (Class I; Level of Evidence: B)
AND
Aspirin 75-100 mg/d (Class I; Level of Evidence: A)
 
Administer
Warfarin to achieve INR of 2.5 for 3 months (Class IIb; Level of Evidence: B)
AND
Aspirin 75-100 mg/d long term (Class IIa; Level of Evidence: B)
 

Administer:

Warfarin to achieve INR of 2.5 for 3 months (Class IIb; Level of Evidence: B), OR
Clopidogrel 75 mg/d (first 6 months) (Class IIb; Level of Evidence: C)
AND
Aspirin 75-100 mg/d (for life) (Class IIa; Level of Evidence: B)
 


†Risk factors for thromboembolism include atrial fibrillation, hypercoagulable conditions, left ventricle dysfunction, and previous thromboembolism.

Do's

  • Order a cardiac MRI in patients with moderate or severe AR with an inconclusive TTE to assess the left ventricular systolic function and the systolic and diastolic volumes, as well as to evaluate the severity of AR (Class I; Level of Evidence: B).[2]

Don'ts

References

  1. Nishimura, RA. (2002). "Cardiology patient pages. Aortic valve disease". Circulation. 106 (7): 770–2. PMID 12176943. Unknown parameter |month= ignored (help)
  2. 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 Nishimura, R. A.; Otto, C. M.; Bonow, R. O.; Carabello, B. A.; Erwin, J. P.; Guyton, R. A.; O'Gara, P. T.; Ruiz, C. E.; Skubas, N. J.; Sorajja, P.; Sundt, T. M.; Thomas, J. D. (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". Circulation. doi:10.1161/CIR.0000000000000031. ISSN 0009-7322.
  3. 3.0 3.1 3.2 Bonow, R. O.; Carabello, B. A.; Chatterjee, K.; de Leon, A. C.; Faxon, D. P.; Freed, M. D.; Gaasch, W. H.; Lytle, B. W.; Nishimura, R. A.; O'Gara, P. T.; O'Rourke, R. A.; Otto, C. M.; Shah, P. M.; Shanewise, J. S. (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–e661. doi:10.1161/CIRCULATIONAHA.108.190748. ISSN 0009-7322.
  4. Williams BR, Steinberg JP (2006). "Images in clinical medicine. Müller's sign". The New England Journal of Medicine. 355 (3): e3. doi:10.1056/NEJMicm050642. PMID 16855259. Retrieved 2012-04-15. Unknown parameter |month= ignored (help)
  5. "http://circ.ahajournals.org/content/121/13/e266.full". External link in |title= (help)
  6. 6.0 6.1 Baddour, LM.; Wilson, WR.; Bayer, AS.; Fowler, VG.; Bolger, AF.; Levison, ME.; Ferrieri, P.; Gerber, MA.; Tani, LY. (2005). "Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Association: endorsed by the Infectious Diseases Society of America". Circulation. 111 (23): e394–434. doi:10.1161/CIRCULATIONAHA.105.165564. PMID 15956145. Unknown parameter |month= ignored (help)


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