Aortic regurgitation natural history, complications and prognosis
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Aortic Regurgitation Microchapters |
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Diagnosis |
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Treatment |
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Acute Aortic regurgitation |
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Chronic Aortic regurgitation |
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Special Scenarios |
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Case Studies |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-in-Chief: Varun Kumar, M.B.B.S., Lakshmi Gopalakrishnan, M.B.B.S.
Overview
Chronic aortic insufficiency is usually insidious and progressive and the patient may remain asymptomatic for years. Once left ventricular dilation and left ventricular failure occurs, dyspnea on exertion and exercise intolerance begins to occur. Later symptoms such as angina, syncope, and other symptoms of heart failure are present. In acute aortic insufficiency symptoms of heart failure can occur acutely.
Natural History
Chronic aortic insufficiency progression in general is slow and insidious; it may remain asymptomatic for years or even decades especially in mild cases. More severe cases can present earlier due to heart failure symptoms; angina and syncope. The left ventricular function should be followed through the measurement of the ejection fraction and the left ventricular end-diastolic dimension to know if an intervention is required.
The prognosis and survival rate for symptomatic aortic regurgitation have been improved dramatically in the last decade; the five year survival rate for symptomatic patients is more than 80 percent.
Complications
Acute severe aortic insufficiency if left untreated can increase risk of morbidity and mortality by causing:
- Left ventricular dysfunction leading to hemodynamic compromise
- Infective endocarditis
- Aortic dissection
Chronic aortic insufficiency if untreated can lead to:
- Heart failure
- Arrhythmia
- Myocardial ischemia
- aortic dissection in patients with bicuspid aortic valve
- Infective endocarditis
Prognosis
Prognosis for patients with aortic insufficiency depends on symptoms and left venticular function[1].
In asymptomatic patients with normal ejection fraction
- Rate of progression to symptoms or left ventricular dysfunction ≤ 6% per year
- Rate of progression to asymptomatic left ventricular dysfunction ≤ 3.5% per year
- Rate of sudden death ≤ 0.2% per year
In asymptomatic patients with decreased ejection fraction
- Rate of progression to symptoms ≥ 25% per year
In symptomatic patients
- Mortality rate ≥ 10% per year
Morbidity and Mortality
Mortality and morbidity in acute severe aortic insufficiency is high due to inability of ventricle to accommodate increased regurgitant volume. Increased left ventricular pressure leads to increase in left atrial and pulmonary pressure, thereby causing pulmonary edema. Decrease in ejection fraction also leads to reduced coronary perfusion resulting in myocardial ischemia and even sudden cardiac death. Early surgical intervention improves the prognosis in these patients.
Chronic aortic insufficiency has a comparatively slower and longer course when asymptomatic. However, the patients rapidly deteriorate once symptoms sets in. Therefore serial echocardiographic assessment of left ventricular function is warranted in asymptomatic patients for determining the need for surgery[1].
Patients with chronic severe aortic insufficiency who are managed conservatively[2]:
- Death from any cause - 4.7% per year
- Congestive heart failure - 6.2% per year
- Aortic valve surgery - 14.6% per year
Asymptomatic Patients:
- Mortality rate - 2.8% per year
Symptomatic patients:
- NYHA class I - 3.0% per year
- NYHA class II - 6.3% per year
- NYHA class III-IV - 24.6% per year
References
- ↑ 1.0 1.1 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 (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): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Retrieved 2011-04-19. Unknown parameter
|month=ignored (help) - ↑ Dujardin KS, Enriquez-Sarano M, Schaff HV, Bailey KR, Seward JB, Tajik AJ (1999). "Mortality and morbidity of aortic regurgitation in clinical practice. A long-term follow-up study". Circulation. 99 (14): 1851–7. PMID 10199882. Retrieved 2011-04-19. Unknown parameter
|month=ignored (help)