Cardiothoracic Surgery: Aortic Regurgitation (AR)

Aortic Regurgitation (AR)

Basics

  • Also Known as Aortic Insufficiency
  • Definition: Inadequate Diastolic Closure of the Aortic Valve
  • A Portion of Stroke Volume to Regurgitate from the Aorta Back into the Left Ventricle
    • Causes Left Ventricle Hypertrophy

Causes

  • Diseased Valve Leaflets
    • Valvular Calcification
    • Bicuspid Aortic Valve
    • Rheumatic Heart Disease – Most Common Cause in Developing Countries
    • Endocarditis
  • Aortic Root Enlargement
    • Aortic Dissection
    • Genetic Disease (Marfan Syndrome, etc.)
    • Trauma

Presentation

  • Symptoms:
    • Exertional Dyspnea
    • Angina
    • Congestive Heart Failure
    • *Symptoms are Uncommon Until Disease is Severe
  • Water-Hammer (Corrigan) Pulse – Rapidly Rising & Falling Arterial Pulse with a Wide Pulse Pressure
  • Early Diastolic Murmur

Diagnosis

  • Diagnosis: Echocardiogram
  • Severity:
Parameter Mild Mild to Moderate Moderately Severe Severe
Width of Vane Contracta < 3.0 mm 3.0-5.9 mm 3.0-5.9 mm ≥ 6.0 mm
Ratio of Central Jet Width to LV Outflow Tract < 25% 25-44% 45-64% ≥ 65%
Regurgitant Volume < 30 ml/Beat 30-44 ml/Beat 45-59 ml/Beat ≥ 60 ml/Beat
Regurgitant Fraction < 30% 30-39% 40-49% ≥ 50%
Effective Regurgitant Orifice < 10 mm2 10-19 mm2 20-29 mm2 ≥ 30 mm2
  • Stages:
    • Stage A: At Risk for AR with Trace-No Current AR
    • Stage B: Mild-Moderate AR with Normal LV Systolic Function
    • Stage C: Asymptomatic Severe AR
      • Stage C1: LV Ejection Fraction Normal (≥ 50%)
      • Stage C2: LV Ejection Fraction Reduced (< 50%)
    • Stage D: Symptomatic Severe AR

General Management

  • Asymptomatic: Monitoring for Disease Progression
  • Symptomatic: Aortic Valve Replacement (AVR)
    • TAVR/TAVI Generally Preferred

Aortic Valve Replacement (AVR) Indications

  • Severe AR If:
    • Symptomatic
    • Left Ventricle (LV) Systolic Dysfunction (EF < 50%)
    • End-Systolic Dimension > 50 mm
    • Progressive Severe LV Dilation (LVEDD > 65 mm) if Low Surgical Risk
    • Undergoing Cardiac Surgery for Other Indications
  • Moderate AR if Undergoing Cardiac Surgery for Other Indications