Aortic Regurgitation

Aortic regurgitation is diastolic reflux of blood from aorta to LV due to malposition of the aortic cusps.

RISK FACTORS

  • age
  • enlarged aortic root diameter: Marfans, Enhlers-Danlos, oesteogenesis imperfecta, connective tissue disorders
  • bicuspid AV
  • atherosclerosis
  • infective endocarditis
  • rheumatic heart disease
  • connective tissue or inflammatory diseases
  • antiphospholipid syndrome
  • trauma
  • ankylosing spondilitis

SYMPTOMS

  • SOBOE
  • angina
  • LVF

EXAMINATION

  • decrescendo diastolic murmur
  • systolic ejection murmur (high ejection volume)
  • absent second heart sound
  • bounding carotid pulse
  • head bobbing
  • uvula pulsation
  • pistol shot sounds over femoral artery
  • compression of finger nails with a glass slide: capillary pulsations

ECHO

Goals

  • look at anatomy of aortic valve leaflets and root
  • assess severity of AR
  • quantify LV size and function

Anatomy

  • leaflets: bicuspid, tricuspid, vegetations, degeneration.
  • annulus: size
  • root: size of sinus of Valsalva, dissection

Severity

  • jet width/LVOT width (< 25% = mild, >65% = severe)

MANAGEMENT

Indications for aortic valve replacement

  • acute AR
  • any symptoms (NYHA II or greater)
  • declining EF
  • declining EF with exercise

Non-surgical issues

  • best to operate before LV end-diastolic diameter increases to >55 mm or 25 mm/m2 or before LVEF falls to <55%
  • avoid beta-blockers (prolongs diastole)
  • intra-aortic balloon pump is contra-indicated
  • decrease afterload in chronic AR (improves LV function)

References

Journal articles and textbooks

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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