Aortic regurgitation general approach to aortic insufficiency

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

Overview

Aortic insufficiency is defined as reverse or backward flow of blood from the aorta into the left ventricle during diastolic phase of the heart beat.

Classification

Aortic insufficiency can be acute or chronic.

Pathophysiology

Pathophysiology of acute aortic regurgitation involves sudden large regurgitant volume of blood imposed on unprepared left ventricle. There will not be any acute left ventricular enlargement as enlargement usually takes place over a period of time. The effective left ventricle stroke volume is reduced because of the reverse flow of blood from aorta. This leads to rapid increase in left ventricular end diastolic pressures. Patients tend to develop pulmonary edema because of the reversal of pressure gradients. Cardiac output is reduced and inturn blood pressure. Tachycardia can not compensate for the lowering cardiac output.

Causes

Aortic insufficiency can be caused by defects in the intrinsic valve or ascending aorta (root).

• Intrinsic Valvular:
  • Degenerative / calcific aortic valve
  • Endocarditis
  • Bicuspid aortic valve
  • Rheumatic fever
  • Valvulitis
  • Anorectic drugs

• Ascending aorta (root):
  • Degenerative
  • Type A aortic dissection
  • Marfan syndrome
  • Giant cell arteries
  • Inflammatory:
    • Reiter's syndrome
    • Behcet's disease
    • Ankylosing spondylitis
    • Relapsing polychondritis
    • Psoriatic arthritis

Differentiating Aortic insufficiency from Mitral regurgitation

Natural History

Two parameters that reflect the overall outcome in patients with aortic insufficiency include:

• Ejection fraction
• End systolic diameter

After the onset of severe regurgitation it takes decades to progress to left ventricular dysfunction. This time period is longer than that for mitral regurgitation.

Lower the ejection fraction poorer the outcome. Ejection values less than 55% have a poor outcome than ≥55%.