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| {{Aortic insufficiency}} | | __NOTOC__ |
| | {{Aortic insufficiency surgery}} |
| | '''For the WikiPatient page for this topic, click [[Aortic valve surgery (patient information)|here]]'''; '''For the main page of aortic insufficiency, click [[Aortic insufficiency|here]]''' |
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| | {{CMG}}; '''Associate Editor-In-Chief:''' [[User:Mohammed Sbeih|Mohammed A. Sbeih, M.D.]][mailto:msbeih@wikidoc.org]; [[Varun Kumar]], M.B.B.S., [[Lakshmi Gopalakrishnan]], M.B.B.S; {{USAMA}} |
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| {{CMG}}; '''Associate Editor-In-Chief:''' {{CZ}}, [[Varun Kumar]], M.B.B.S., [[Lakshmi Gopalakrishnan]], M.B.B.S.
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| '''Related Key Words and Synonyms:''' Aortic valve replacement. | | '''Related Key Words and Synonyms:''' Aortic valve replacement. |
| ==Overview==
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| Surgical treatment is controversial in asymptomatic patients. Surgery may be recommended if the [[ejection fraction]] falls below 50% or in the face of progressive and severe left ventricular dilatation. For both groups of patients, surgery before the development of worse aortic insufficiency [[ejection fraction]]/LV systolic dilatation, is expected to reduce the risk of [[sudden death]], and is associated with lower peri-operative mortality.
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| The majority of patients with severe aortic regurgitation requiring surgery undergo [[aortic valve replacement]] against [[aortic valve repair]] which are preformed at few surgical centers which have appropriate technical expertise and experience in selecting potential patients.
| | ==[[Aortic insufficiency surgery overview|Overview]]== |
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| ==ACC/AHA Guidelines- Indications for [[Aortic Valve Replacement|Aortic Valve Replacement/Repair]] in Chronic [[Aortic Insufficiency]] (DO NOT EDIT) <ref name="pmid18848134">{{cite journal| author=Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD et al.| 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=J Am Coll Cardiol | year= 2008 | volume= 52 | issue= 13 | pages= e1-142 | pmid=18848134 | doi=10.1016/j.jacc.2008.05.007 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18848134 }} </ref>== | | ==[[Aortic insufficiency surgery indications|Indications]]== |
| {{cquote|
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| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
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| '''1.''' AVR is indicated for symptomatic patients with severe AR irrespective of LV systolic function. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
| | ==[[Aortic insufficiency surgery preoperative evaluation|Preoperative Evaluation]]== |
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| '''2.''' AVR is indicated for asymptomatic patients with chronic severe aortic insufficiency and [[left ventricular systolic dysfunction]] ([[ejection fraction]] 50% or less) at rest. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
| | ==[[Aortic insufficiency surgery valve selection|Valve Selection]]== |
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| '''3.''' AVR is indicated for patients with chronic severe aortic insufficiency while undergoing [[coronary artery bypass graft]](CABG) or surgery on the aorta or other heart valves. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])
| | ==[[Aortic insufficiency surgery procedure|Procedure]]== |
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| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
| | ==[[Aortic insufficiency surgery recovery|Recovery]]== |
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| '''1.''' AVR is reasonable for asymptomatic patients with severe aortic insufficiency with normal left ventricular systolic function ([[ejection fraction]] greater than 50%) but with severe left ventricular dilatation (end-diastolic dimension greater than 75 mm or end-systolic dimension greater than 55 mm). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])
| | ==[[Aortic insufficiency surgery prognosis|Outcomes & Prognosis]]== |
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| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]===
| | ==[[Aortic insufficiency surgery complications|Complications]]== |
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| '''1.''' AVR may be considered in patients with moderate aortic insufficiency while undergoing surgery on the ascending aorta. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])
| | ==[[Aortic insufficiency surgery videos|Videos]]== |
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| '''2.''' AVR may be considered in patients with moderate aortic insufficiency while undergoing [[CABG]]. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])
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| '''3.''' AVR may be considered for asymptomatic patients with severe aortic insufficiency and normal left ventricular systolic function at rest ([[ejection fraction]] greater than 50%) when the degree of left ventricular dilatation exceeds an end-diastolic dimension of 70 mm or end-systolic dimension of 50 mm, when there is evidence of progressive left ventricular dilatation, declining exercise tolerance, or abnormal hemodynamic responses to exercise. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])
| | [[CME Category::Cardiology]] |
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| ===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]===
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| '''1.''' AVR is not indicated for asymptomatic patients with mild, moderate, or severe aortic insufficiency and normal left ventricular systolic function at rest ([[ejection fraction]] greater than 50%) when the degree of dilatation is not moderate or severe (end-diastolic dimension less than 70 mm, end-systolic dimension less than 50 mm). ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])}}
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| ==Surgical Management of Chronic Aortic Insufficiency==
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| ===Indications for surgery for chronic severe aortic insufficiency===
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| {| border="1" cellpadding="5" cellspacing="0" align="left"
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| |+ '''Indications for surgery for chronic severe aortic insufficiency'''<ref>{{cite journal |author= |title=ACC/AHA 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 (Committee on Management of Patients with Valvular Heart Disease) |journal=J. Am. Coll. Cardiol. |volume=32 |issue=5 |pages=1486–588 |year=1998 |pmid=9809971 |doi=}}</ref>
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| |-----
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| ! style="background:#efefef;" width="150px" | Symptoms
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| ! style="background:#efefef;" width="100px" | Ejection fraction
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| ! style="background:#efefef;" width="150px" | Other information
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| |-----
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| | [[New York Heart Association Functional Classification|NYHA class]] III - IV
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| | ≥ 50 % ||
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| | NYHA class II || ≥ 50 %
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| | Progression of symptoms or worsening parameters on echocardiography
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| | CHA class ≥ II [[Angina pectoris|angina]] || ≥ 50 % ||
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| | Regardless of symptoms || 25 - 49 % ||
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| |-----
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| | colspan="3" | Cardiac surgery for other cause (ie: [[coronary artery disease|CAD]], other valvular disease, ascending aortic aneurysm)
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| |}
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| Surgical corrections of regurgitant aortic valve have shown to improve symptoms in symptomatic patients with severe aortic insufficiency. In some studies, the left ventricular function ([[ejection fraction]]) also was seen to improve with AVR<ref name="pmid3156010">{{cite journal |author=Daniel WG, Hood WP, Siart A, Hausmann D, Nellessen U, Oelert H, Lichtlen PR |title=Chronic aortic regurgitation: reassessment of the prognostic value of preoperative left ventricular end-systolic dimension and fractional shortening |journal=[[Circulation]] |volume=71 |issue=4 |pages=669–80 |year=1985 |month=April |pmid=3156010 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=3156010 |accessdate=2011-03-27}}</ref> <ref name="pmid3668112">{{cite journal |author=Carabello BA, Usher BW, Hendrix GH, Assey ME, Crawford FA, Leman RB |title=Predictors of outcome for aortic valve replacement in patients with aortic regurgitation and left ventricular dysfunction: a change in the measuring stick |journal=[[Journal of the American College of Cardiology]] |volume=10 |issue=5 |pages=991–7 |year=1987 |month=November |pmid=3668112 |doi= |url= |accessdate=2011-03-27}}</ref>.
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| In severe aortic insufficiency, new onset of mild symptoms are also candidates for AVR. It is recommended that surgery should not be delayed till development of advanced symptoms as this may result in development of some degree of irreversible left ventricular dysfunction <ref name="pmid9283535">{{cite journal |author=Klodas E, Enriquez-Sarano M, Tajik AJ, Mullany CJ, Bailey KR, Seward JB |title=Optimizing timing of surgical correction in patients with severe aortic regurgitation: role of symptoms |journal=[[Journal of the American College of Cardiology]] |volume=30 |issue=3 |pages=746–52 |year=1997 |month=September |pmid=9283535 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(97)00205-2 |accessdate=2011-03-27}}</ref> <ref name="pmid15261934">{{cite journal |author=Carabello BA |title=Is it ever too late to operate on the patient with valvular heart disease? |journal=[[Journal of the American College of Cardiology]] |volume=44 |issue=2 |pages=376–83 |year=2004 |month=July |pmid=15261934 |doi=10.1016/j.jacc.2004.03.061 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109704007958 |accessdate=2011-03-27}}</ref>. Patients who are symptomatic with [[NYHA]] Class IV, have poor outcome post AVR with less likelihood of improvement of left ventricular systolic function <ref name="pmid2972417">{{cite journal |author=Bonow RO, Dodd JT, Maron BJ, O'Gara PT, White GG, McIntosh CL, Clark RE, Epstein SE |title=Long-term serial changes in left ventricular function and reversal of ventricular dilatation after valve replacement for chronic aortic regurgitation |journal=[[Circulation]] |volume=78 |issue=5 Pt 1 |pages=1108–20 |year=1988 |month=November |pmid=2972417 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=2972417 |accessdate=2011-03-27}}</ref> <ref name="pmid6451163">{{cite journal |author=Greves J, Rahimtoola SH, McAnulty JH, DeMots H, Clark DG, Greenberg B, Starr A |title=Preoperative criteria predictive of late survival following valve replacement for severe aortic regurgitation |journal=[[American Heart Journal]] |volume=101 |issue=3 |pages=300–8 |year=1981 |month=March |pmid=6451163 |doi= |url= |accessdate=2011-03-27}}</ref> <ref name="pmid4064269">{{cite journal |author=Bonow RO, Picone AL, McIntosh CL, Jones M, Rosing DR, Maron BJ, Lakatos E, Clark RE, Epstein SE |title=Survival and functional results after valve replacement for aortic regurgitation from 1976 to 1983: impact of preoperative left ventricular function |journal=[[Circulation]] |volume=72 |issue=6 |pages=1244–56 |year=1985 |month=December |pmid=4064269 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=4064269 |accessdate=2011-03-27}}</ref> <ref name="pmid7351849">{{cite journal |author=Cunha CL, Giuliani ER, Fuster V, Seward JB, Brandenburg RO, McGoon DC |title=Preoperative M-mode echocardiography as a predictor of surgical results in chronic aortic insufficiency |journal=[[The Journal of Thoracic and Cardiovascular Surgery]] |volume=79 |issue=2 |pages=256–65 |year=1980 |month=February |pmid=7351849 |doi= |url= |accessdate=2011-03-27}}</ref>. But with AVR, ventricular loading conditions are improved and expedite subsequent management of [[left ventricular dysfunction]]<ref name="pmid7351067">{{cite journal |author=Clark DG, McAnulty JH, Rahimtoola SH |title=Valve replacement in aortic insufficiency with left ventricular dysfunction |journal=[[Circulation]] |volume=61 |issue=2 |pages=411–21 |year=1980 |month=February |pmid=7351067 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=7351067 |accessdate=2011-03-28}}</ref>.
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| Symptomatic patients even with mild to moderate left ventricular systolic dysfunction (ejection fraction 25%- 50%) should also undergo AVR. AHA/ACC guidelines recommends that patients with [[NYHA]] Class II and III symptoms should undergo valve replacement if <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=2011-03-28}}</ref>:
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| {{cquote| | |
| #symptoms and evidence of [[left ventricular dysfunction]] are of recent onset
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| #intensive short-term therapy with [[vasodilators]] and [[diuretics]] results in symptomatic improvement
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| #intravenous [[positive inotropic]] agents result in substantial improvement in hemodynamics or systolic function.}}
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| Aortic valve replacement/repair is not recommended in a truly asymptomatic patient with normal left ventricular function (left ventricular [[ejection fraction]] ≥50%) without severe left ventricular dilatation because this would expose the patient to perioperative mortality risk of 4% against less than 0.2% mortality risk without surgery and other long-term complications of a [[prosthetic heart valve]]<ref name="pmid15998697">{{cite journal |author=Bekeredjian R, Grayburn PA |title=Valvular heart disease: aortic regurgitation |journal=[[Circulation]] |volume=112 |issue=1 |pages=125–34 |year=2005 |month=July |pmid=15998697 |doi=10.1161/CIRCULATIONAHA.104.488825 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=15998697 |accessdate=2011-03-28}}</ref>. In such patients 2006 AHA/ACC guidelines recommends <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=2011-03-28}}</ref>:
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| *Patients with mild chronic [[aortic insufficiency]] with normal left ventricular [[ejection fraction]] should undergo clinical evaluation yearly and [[echocardiography]] every two to three years.
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| *Patients with severe chronic [[aortic insufficiency]] with normal left ventricular ejection fraction should be followed up based on ventricular dimensions:
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| #Patients with end-systolic ventricular dimension '''<45 mm''' and end-diastolic ventricular dimension '''<60 mm''' should undergo clinical evaluation every 6-12months and [[echocardiography]] every 12months. However, if the patient is not stable or this is the initial study, he should be re-evaluated and [[echocardiography]] performed in 3months.
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| #Patients with end-systolic ventricular dimension '''45-50 mm''' and end-diastolic ventricular dimension '''60-70 mm''' should undergo clinical evaluation every 6months and [[echocardiography]] every 12months. However, if the patient is not stable or this is the initial study, he should be re-evaluated and [[echocardiography]] performed in 3months.
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| #Patients with end-systolic ventricular dimension '''50-55 mm''' and end-diastolic ventricular dimension '''70-75 mm''' with '''normal hemodynamic response to exercise''' should undergo clinical evaluation every 6months and [[echocardiography]] every 6months. However, if the patient is not stable or this is the initial study, he should be re-evaluated and [[echocardiography]] performed in 3 months.
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| While interpreting these breakpoints of left ventricular dimensions, body size of the patients should also be taken into consideration. Because women or patients with small body size may not be able to achieve ventricular dimensions mentioned above as they were established in men <ref name="pmid6707364">{{cite journal |author=Stone PH, Clark RD, Goldschlager N, Selzer A, Cohn K |title=Determinants of prognosis of patients with aortic regurgitation who undergo aortic valve replacement |journal=[[Journal of the American College of Cardiology]] |volume=3 |issue=5 |pages=1118–26 |year=1984 |month=May |pmid=6707364 |doi= |url= |accessdate=2011-03-28}}</ref> <ref name="pmid8921790">{{cite journal |author=Klodas E, Enriquez-Sarano M, Tajik AJ, Mullany CJ, Bailey KR, Seward JB |title=Surgery for aortic regurgitation in women. Contrasting indications and outcomes compared with men |journal=[[Circulation]] |volume=94 |issue=10 |pages=2472–8 |year=1996 |month=November |pmid=8921790 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=8921790 |accessdate=2011-03-28}}</ref>. Body surface area when considered for left ventricular dimension, tend to mask the diagnosis of left ventricular enlargement, especially in patients who
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| are overweight<ref name="pmid12633821">{{cite journal |author=Mathew RK, Gaasch WH, Guilmette NE, Schick EC, Labib SB |title=Anthropometric normalization of left ventricular size in chronic mitral regurgitation |journal=[[The American Journal of Cardiology]] |volume=91 |issue=6 |pages=762–4 |year=2003 |month=March |pmid=12633821 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0002914902034276 |accessdate=2011-03-28}}</ref>. Therefore patient's height and gender should be considered during interpretation of ventricular dimensions. <ref name="pmid9323074">{{cite journal |author=Vasan RS, Larson MG, Levy D, Evans JC, Benjamin EJ |title=Distribution and categorization of echocardiographic measurements in relation to reference limits: the Framingham Heart Study: formulation of a height- and sex-specific classification and its prospective validation |journal=[[Circulation]] |volume=96 |issue=6 |pages=1863–73 |year=1997 |month=September |pmid=9323074 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=9323074 |accessdate=2011-03-28}}</ref>
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| ===Preoperative Evaluation===
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| The patient may need to have some tests before the procedure. After the diagnosis of aortic insufficiency, the general health of the patient should be assessed and the most appropriate treatment should be recommended. Some of the '''tests that can be done before the procedure''' include:
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| *[[Echocardiogram]] (Doppler echocardiogram).
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| *[[Cardiac catheterization]].
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| *Chest X-ray.
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| *Computed tomography (CT) scan.
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| *[[Electrocardiogram]] (ECG).
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| *[[Electrophysiology]] tests.
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| *Exercise tests.
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| *[[Holter monitor]].
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| *[[Magnetic resonance imaging]] (MRI).
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| Cardiac catheterization in patients with chronic aortic insufficiency is recommended if the noninvasive diagnostic tests are inconclusive, or if the patient is at risk of coronary heart disease and the coronary anatomy should be assessed.
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| Other aortic root diseases like [[marfan syndrome]], [[bicuspid aortic valve]] and [[aortic dissection]] which can cause chronic aortic regurgitation should be treated with AVR and aortic root reconstruction when degree of dilatation of aorta or aortic root ≥ 50mm in diameter <ref name="pmid9339352">{{cite journal |author=Lindsay J |title=Diagnosis and treatment of diseases of the aorta |journal=[[Current Problems in Cardiology]] |volume=22 |issue=10 |pages=485–542 |year=1997 |month=October |pmid=9339352 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0146-2806(97)80004-7 |accessdate=2011-03-28}}</ref>
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| '''Ross''' or '''Ross/Konno procedure''' is another alternative surgical procedure where the [[pulmonary valve]] is transplanted to the aortic position, and a [[homograft conduit]] is implanted from the right ventricle to the pulmonary artery. Though this procedure shows promising results for aortic valve abnormalities in some<ref name="pmid11565665">{{cite journal |author=Ohye RG, Gomez CA, Ohye BJ, Goldberg CS, Bove EL |title=The Ross/Konno procedure in neonates and infants: intermediate-term survival and autograft function |journal=[[The Annals of Thoracic Surgery]] |volume=72 |issue=3 |pages=823–30 |year=2001 |month=September |pmid=11565665 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0003-4975(01)02814-4 |accessdate=2011-04-08}}</ref><ref name="pmid11436048">{{cite journal |author=Laudito A, Brook MM, Suleman S, Bleiweis MS, Thompson LD, Hanley FL, Reddy VM |title=The Ross procedure in children and young adults: a word of caution |journal=[[The Journal of Thoracic and Cardiovascular Surgery]] |volume=122 |issue=1 |pages=147–53 |year=2001 |month=July |pmid=11436048 |doi=10.1067/mtc.2001.113752 |url=http://linkinghub.elsevier.com/retrieve/pii/S0022-5223(01)41212-8 |accessdate=2011-04-08}}</ref><ref name="pmid12354710">{{cite journal |author=Laforest I, Dumesnil JG, Briand M, Cartier PC, Pibarot P |title=Hemodynamic performance at rest and during exercise after aortic valve replacement: comparison of pulmonary autografts versus aortic homografts |journal=[[Circulation]] |volume=106 |issue=12 Suppl 1 |pages=I57–I62 |year=2002 |month=September |pmid=12354710 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=12354710 |accessdate=2011-04-08}}</ref>, the use of this technique has been limited by high rates of pulmonary autograft failure with deterioration of right heart homografts<ref name="pmid19153280">{{cite journal |author=David TE |title=Ross procedure at the crossroads |journal=[[Circulation]] |volume=119 |issue=2 |pages=207–9 |year=2009 |month=January |pmid=19153280 |doi=10.1161/CIRCULATIONAHA.108.827964 |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=19153280 |accessdate=2011-04-08}}</ref>. These rates are higher in children as compared to adults. Further studies aimed at clarifying longer-term outcomes as well as preventing pulmonary homograft deteroration are needed.
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| {{#ev:youtube|r50kKpKefP8}}
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| To summarize, mechanical valve replacement is the preferred surgical option at present as opposed to valve repair or biological valve replacement in view of lack of evidence of long-term durability and outcomes. However, they may be appropriate for patients in whom [[anticoagulation]] are contraindicated. Patients' age, ability to tolerate [[warfarin]] and patients' preference are taken into account for in deciding the type of valve (mechanical or bioprosthetic valve) to be used in valve replacement. <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=2011-03-29}}</ref>
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| ==Severe aortic insufficiency in patient after aortic valve replacement 1==
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| {{#ev:googlevideo|-3829359717394053857}}
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| ==Severe aortic insufficiency in patient after aortic valve replacement 2==
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| {{#ev:googlevideo|-1139143783733805104}}
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| ==Severe aortic insufficiency in patient after aortic valve replacement 3==
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| {{#ev:googlevideo|-7501177211861270942}}
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| ==Severe aortic insufficiency in patient after aortic valve replacement 4==
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| {{#ev:googlevideo|-4027195456056520519}}
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| ==Severe aortic insufficiency in patient after aortic valve replacement 5==
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| {{#ev:googlevideo|3983126063629833286}}
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| ==Severe aortic insufficiency in patient after aortic valve replacement 6==
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| {{#ev:googlevideo|5313961274473108141}}
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| ==Severe aortic insufficiency in patient after aortic valve replacement 7==
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| {{#ev:googlevideo|-1049019986268408841}}
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| ==Severe aortic insufficiency in patient after aortic valve replacement 8==
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| {{#ev:googlevideo|1577454681656420080}}
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| ==References==
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| {{reflist|2}}
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
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| [[Category:Cardiac surgery]] | | [[Category:Cardiac surgery]] |
| [[Category:Surgical procedures]] | | [[Category:Surgical procedures]] |
| | | [[Category:Valvular heart disease]] |
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