Aortic Regurgitation – Symptoms, Diagnosis And Treatment
The inability of aortic valve, due to pathological processes, to close during the ventricular diastole, with the return of a quantity of blood from aorta to the left ventricle, define the aortic regurgitation.
Aortic valve regurgitation occurs when the aortic valve does not work properly. To understand this, you must know the normal mechanism of action of the aortic valve. Aortic valve works like an open gate in a unique way so that blood from the left ventricle (the heart’s main pump) can pass into the aorta (main artery that leaves the heart). From the aorta, oxygenated blood passes into the smaller arteries and then throughout the entire body to nourish tissues. When the heart rests between beats, the aortic valve closes to prevent blood flowing back into his heart.
Various pathological processes may affect the elements of the aortic root, resulting acut or chronic aortic regurgitation.
Acute aortic regurgitation:
- Acute aortic dissection;
- Postinterventional (balloon dilation of aortic stenosis);
Chronic aortic regurgitation:
- Aneurysms of ascending aorta;
- Marfan Syndrome;
- Severe high blood pressure with long evolution;
- Ankylosing spondylitis, rheumatoid arthritis, giant cell aortitis;
- Ehler-Danlos syndrome;
- Reiter’s syndrome.
Return of blood from the aorta into the left ventricle during diastole, due to aortic valve incompetence, is the essential haemodynamic change, that condition the appearance of heart modifications. If is a acute aortic regurgitation, then a massive and sudden volume of regurgitant blood surprises the left ventricle, of normal size, not adapted. The result is a fast and brutal increase of pressure in the left atrium and left ventricle with acute ventricular failure, acute pulmonary edema and cardiogenic shock. In these situation is needed emergency surgery to save the patient’s life. If the installation of aortic regurgitation is progressive, then the left ventricle adapts for a long time by its dilation and will increase its compliance, to maintain a normal end-diastolic pressure. Patients are asymptomatic during this period. Heart grows to a certain point, the compliance will decrease, end-diastolic pressure in left ventricle will increase, systolic function is depressed and will appear left ventricular failure and patients will be symptomatic with signs of heart failure, effort and sleep dyspnoea, fatigue and pulmonary edema.
Symptoms and diagnosis of aortic regurgitation:
A long period of time patients are asymptomatic. Then, will appear symptoms like dyspnoea, palpitations, fatigue, sweating and angina pectoris. Clinical examination will revel a large pulse, “celer et altus” (Corrigan pulse), the Musset sign (rhythmic tilt of the head), Hill sign (femoral blood pressure is 60 mmHg higher than brachial) blood pressure have divergent values, strong apexian shock and musical aortic systolic murmur.
After examining the patient, paraclinical investigations will specify the exact severity of aortic regurgitation, the effects on the heart, on other valves and on coronary system.
Radiological examination. Highlight the size of the left ventricle, left atrium and of the aorta. In early forms, the radiography is normal, then will appear a dilated left ventricle, a dilated ascending aorta and signs of pulmonary stasis.
Electrocardiogram. Normal at first, then will appear signs of left ventricular hypertrophy, arrhythmias, atrial fibrillation and sometimes can appear ischemic changes.
Echocardiography. Transthoracic and transoesophageal performed in two-dimensional mode and Doppler mode will bring crucial elements in deciding the treatment of atrial regurgitation. Ecocardiography is useful in the diagnosis of the aortic regurgitation because:
- Confirm an asses the acute aortic regurgitation;
- Confirm the diagnosis of chronic aortic regurgitation;
- May specify the etiology of aortic regurgitation, aortic dissection, endocarditis with vegetation;
- Rate the effects on left ventricle;
- Evaluates the condition of the mitral, tricuspid and pulmonary valve and the pulmonary hypertension;
Cardiac catheterization. Is routinely performed in all patients over 40 years to investigate the coronary system, dilation of aortic root or if are other vascular associated disease, carotid system and peripheral arteries. This exploartion rate the severity of aortic regurgitation, size and function of the left ventricle, valvular lesions associated, pressure in the heart chambers, pulmonary vascular resistance and will perform the calculation of the pulmonary hypertension.
Medical treatment. In asymptomatic patients is not required any treatment in the absence of hypertension. It is recommended only general measures, hygienic-dietary, elimination of cardiovascular risk factors (smoking, obesity), infectious endocarditis prophylaxis and regular monitoring of the disease. If the symptoms will appear, then is recommended vasodilatators to reduce regurgitant volume, converting enzyme inhibitors, reevaluate the patient for surgical indication before will appear severe decompensation of the heart.
Surgical treatment. Optimal timing for surgery in aortic regurgitation is more difficult to be choose than for aortic stenosis due to the long asymptomatic evolution of the disease. Surgical indication in asymptomatic patients with severe aortic regurgitation is controversial, due to good natural evolution of the disease. On the other hand,ventricular decompensation once occurred, can reduce the chances of recovery of the cardiac function and the survival rate after surgery. Surgical indications accepted by most authors are:
- Asymptomatic patients with progressive heart enlargement, progressive left ventricular hypertrophy, reduction of left ventricular ejection fraction <45% or end-diastolic diameter of the left ventricle > 70 mm;
- Symptomatic patients with angina pectoris or heart failure;
- Acute aortic regurgitation;
- Acute bacterial endocarditis with severe aortic regurgitation and risk of septic embolism.