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  • Aortic valve (AV): Usually tricuspid, composed of fibrous skeleton, 3 cusps, and sinuses of Valsalva

    • Free edge of each cusp is concave and thicker, with fibrous node at midpoint

    During systole: Eddy currents in sinuses of Valsalva prevent occlusion of coronary ostia

    During diastole: Cusps fall closed and coapt, supports ejected column of blood

    • Coronary arteries arise from 2 of 3 sinuses of Valsalva

    • Aortic regurgitation (AR) is caused by abnormal coaptation of valve leaflets, allowing blood to return from aorta to ventricle during diastole

    • Etiology of chronic AR:

    • -Rheumatic dilation

      -Annuloaortic ectasia

      -Cystic medial necrosis

      -Atherosclerosis

      -Syphilis

      -Arthritic inflammatory disease

      -Congenital bicuspid valve

    • Etiology of acute AR:

    • -Endocarditis

      -Acute aortic dissection

      -Trauma

    • LV becomes eccentrically hypertrophied and dilated

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Epidemiology

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  • • Causes of valve disease: rheumatic carditis (most common), valve collagen degeneration, infection

    • Less common causes: Collagen-vascular disease, tumors, carcinoid, and Marfan syndrome

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Symptoms and Signs

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  • • Acute AR:

    • -Poorly tolerated

      -Severe pulmonary edema, congestive heart failure (CHF)

      -If diastolic murmur absent, indicates complete valve incompetence

    • Chronic AR:

    • -Patients with early disease are asymptomatic

      -Orthopnea, paroxysmal dyspnea, and CHF develops later

    • Wide pulse pressure, diastolic pressure low (Corrigan pulse)

    • Apical impulse: Sustained and lateral and inferiorly displaced

    • Blowing high-pitched diastolic murmur heard at left lower sternal border at full expiration

    • Third heart sound may be present

    • Austin-Flint murmur: Diastolic rumbling—secondary mitral valve obstruction

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Laboratory Findings

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  • • ECG: LV hypertrophy with left axis deviation

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Imaging Findings

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  • Chest film

    • -Usually normal cardiac size

      -If chronic AR, LV enlargement, pulmonary congestion

    Echocardiography: Demonstrates LV function, chamber size, degree of regurgitation

    Catheterization: Define degree of AR and coronary artery, aortic root anatomy

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  • • Evaluate for other valvular disease and secondary LV dysfunction

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  • • Echocardiographic measurement of LV dimensions: Significant ventricular dilation = LV end-diastolic dimension > 70 mm, or end-systolic > 50 mm

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  • • Vasodilator therapy

    • -Useful in asymptomatic patients

      -Will not prevent need for future surgery

    • AV replacement is standard

    • Select patients can have valve repair with subcommissural annuloplasty if the lesion is simple annular dilation

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Surgery

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Indications

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  • • Replace valve before onset of irreversible LV dilation (see Work-up)

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Prognosis

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  • • Medical therapy: 5- and 10-year mortality in severe AR is 25% and 50%, respectively

    • 5-year survival postoperatively with normal ventricular function is 85%

    • Abnormal LV function affects long-term survival

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References

Bonow RO et al: 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 Circulation. J Am Coll Cardiol 2006;48:e1.
Roberts WC et al: Causes of pure ...

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