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| __NOTOC__
| | #Redirect [[Aortic regurgitation surgery indications#Indications for Surgery for Acute Aortic Regurgitation]] |
| {{Aortic insufficiency}}
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| {{CMG}}; {{AE}} {{CZ}}; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.
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| ==Overview==
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| Severe acute [[aortic insufficiency]] requires emergency surgery if there are no absolute contraindications to surgery.
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| ==Surgery==
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| ===Timing of Emergency Surgery===
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| Acute severe aortic insufficiency may cause death due to [[pulmonary edema]], [[ventricular arrhythmias]], [[electromechanical dissociation]], or [[circulatory collapse]]. Individuals with [[bacteremia]] with [[aortic valve]] [[endocarditis]] should not wait for treatment with [[antibiotic]]s to take effect, especially if there is [[hypotension]], [[pulmonary edema]], or low [[cardiac output]] given the high mortality associated with the acute [[aortic insufficiency]].
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| Shown below is an algorithm for the treatment of acute [[aortic regurgitation]].<ref name="NishimuraOtto2014">{{cite journal|last1=Nishimura|first1=R. A.|last2=Otto|first2=C. M.|last3=Bonow|first3=R. O.|last4=Carabello|first4=B. A.|last5=Erwin|first5=J. P.|last6=Guyton|first6=R. A.|last7=O'Gara|first7=P. T.|last8=Ruiz|first8=C. E.|last9=Skubas|first9=N. J.|last10=Sorajja|first10=P.|last11=Sundt|first11=T. M.|last12=Thomas|first12=J. D.|title=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|journal=Circulation|year=2014|issn=0009-7322|doi=10.1161/CIR.0000000000000031}}</ref>
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| <span style="font-size:85%">'''Abbreviations:''' '''AVR:''' [[Aortic valve replacement]]; '''ACE:''' [[Angiotensin converting enzyme]]; '''ARB:''' [[Angiotensin receptor blocker]]; '''CCB:''' [[Calcium channel blocker]]; '''LVEF:''' [[Ejection fraction|Left ventricle ejection fraction]]; '''TTE:''' [[Transthoracic echocardiography]] </span>
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| {{Familytree/start}}
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| {{Family tree | | | | | A01 | | | | A01= What is the cause of acute AR?}}
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| {{Family tree | | | |,|-|^|-|.| | | | | | | }}
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| {{Family tree | | | B01 | | B02 | | B01= [[Infective endocarditis]]| B02= [[Aortic dissection]]}}
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| {{Family tree | | | |!| | | |!| | | | | | | }}
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| {{Family tree | | | C01 | | C02 | | C01= <div style="text-align: left; width: 13em">Does the patient have AR related [[heart failure]] symptoms?</div>| C02= <div style="text-align: left; width: 13em">❑ Schedule for an emergent surgery<ref name="circ.ahajournals.org">{{Cite web | last = | first = | title = http://circ.ahajournals.org/content/121/13/e266.full | url = http://circ.ahajournals.org/content/121/13/e266.full | publisher = | date = | accessdate = }}</ref> <br> ❑ Administer [[beta blockers]] with caution (beta blockers inhibit compensatory [[tachycardia]]) </div>}}
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| {{Family tree | |,|-|^|-|.| | | | | | | | | }}
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| {{Family tree | D01 | | D02 | | | | D01= Yes| D02= No}}
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| {{Family tree | |!| | | |!| | | | | | | | | }}
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| {{Family tree | E01 | | E02 | | | | E01= <div style="text-align: left; width: 13em">❑ Schedule for early aortic valve replacement ([[ACC AHA guidelines classification scheme|Class I, level of evidence B]])<ref name="Baddour-2005">{{Cite journal | last1 = Baddour | first1 = LM. | last2 = Wilson | first2 = WR. | last3 = Bayer | first3 = AS. | last4 = Fowler | first4 = VG. | last5 = Bolger | first5 = AF. | last6 = Levison | first6 = ME. | last7 = Ferrieri | first7 = P. | last8 = Gerber | first8 = MA. | last9 = Tani | first9 = LY. | title = 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. | journal = Circulation | volume = 111 | issue = 23 | pages = e394-434 | month = Jun | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.165564 | PMID = 15956145 }}</ref> <br> ''Click '''[[infective endocarditis resident survival guide|here]]''' for more details'' </div>| E02= <div style="text-align: left; width: 13em">❑ Administer [[Endocarditis antimicrobial treatment|antibiotics]]<ref name="Baddour-2005">{{Cite journal | last1 = Baddour | first1 = LM. | last2 = Wilson | first2 = WR. | last3 = Bayer | first3 = AS. | last4 = Fowler | first4 = VG. | last5 = Bolger | first5 = AF. | last6 = Levison | first6 = ME. | last7 = Ferrieri | first7 = P. | last8 = Gerber | first8 = MA. | last9 = Tani | first9 = LY. | title = 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. | journal = Circulation | volume = 111 | issue = 23 | pages = e394-434 | month = Jun | year = 2005 | doi = 10.1161/CIRCULATIONAHA.105.165564 | PMID = 15956145 }}</ref> <br> ❑ Follow up the patient <br> ''Click '''[[infective endocarditis resident survival guide|here]]''' for more details'' </div>}}
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| {{Familytree/end}}
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| ===Type of Surgery===
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| Replacement with an [[artificial heart valve|aortic valve]] [[homograft]] should be performed if feasible. The surgical approach depends upon the cause of aortic insufficiency. [[Aortic valve replacement]] or repair may be needed in cases of valvular structural abnormalities and [[aortic root]] repair/replacement may be needed in cases of [[aortic dissection]].
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| ===Preoperative Medical Therapy===
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| Patients may be temporarily managed before surgery with [[vasodilators]] such as [[nitroprusside]] and possibly [[inotropic agents]] such as [[dopamine]] or [[dobutamine]] to improve [[stroke volume]] and reduce left ventricular end-diastolic pressure.<ref name="pmid18820172">{{cite journal |author=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 |title=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 |journal=[[Circulation]] |volume=118 |issue=15 |pages=e523–661 |year=2008 |month=October |pmid=18820172 |doi=10.1161/CIRCULATIONAHA.108.190748 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=18820172 |accessdate=2011-04-07}}</ref> [[Intra-aortic balloon pump]] is contraindicated as this would worsen aortic regurgitation by increasing [[afterload]].
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| ===Mild Acute Aortic Insufficiency in the Setting of Aortic Dissection===
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| In mild aortic insufficiency secondary to [[aortic dissection]], the [[aortic valve]] can be repaired/replaced at the time of surgery for [[aortic dissection]].
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| ===[[Aortic insufficiency surgical therapy|Aortic Insufficiency Surgical Therapy]]===
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| ==References==
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| {{reflist|2}}
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| [[Category:Disease]]
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| [[Category:Cardiology]]
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| [[Category:Valvular heart disease]]
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| [[Category:Congenital heart disease]]
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| [[Category:Surgery]]
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| [[Category:Cardiac surgery]]
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| [[Category:Emergency medicine]]
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| [[Category:Intensive care medicine]]
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| [[Category:Up-To-Date cardiology]]
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| [[Category:Up-To-Date]]
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| {{WH}}
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| {{WS}}
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