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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2693_Библиотеки_им_академика_М_И_Перельмана.pdf
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diastolic backow from the aorta into the left ventricular outow tract. AO aorta,
LA left atrium, LV left ventricle, RV right ventricle. (b) Flow measurement in the
aortic arch in severe aortic regurgitation. Colour Doppler shows retrograde ow in
the aortic arch which is displayed red. Pulsed Doppler shows diastolic backow
displayed above the baseline. (c) Flow measurement in the anterior cerebral artery
in a patient with severe aortic regurgitation. Diastolic backow caused by severe
aortic regurgitation [Deeg K-H.Cardiovascular Diseases Which Inuence the Flow
in the Extracardial Arteries. In: Deeg K-H, Rupprecht T, Hofbeck M, authors.
Doppler Sonography in Infancy and Childhood [Internet]. Cham: Springer
International Publishing; 2015 [cited 2016 Apr 4]. p.679–730. Available from:
http://link.springer.com/10.1007/978-3-319-03506-2_15] Caption from original
C. J. Rees et al.
Special Populations
Age
• Aortic regurgitation is more common in middle-aged and older adults, especially because the latent period before the appearance of symptoms may be
two decades.
• Aortic regurgitation may be seen in children, in whom it is usually associated
with either severe aortic stenosis or a ventricular septal defect. Most cases in
children are mild and asymptomatic, and need only be followed with serial
exams and echocardiography.
Co-morbidities
• Aortic regurgitation may be diagnosed in relatively healthy patients but also
may present in the setting of numerous other cardiovascular diseases and
risks.
Pitfalls inDiagnosis
Critical Steps Not toMiss
• Consideration of the diagnosis is the rst critical step. In patients with hemodynamic compromise, an echocardiogram should be performed early to assess
all hemodynamic parameters and determine the need for urgent operative
intervention.
8 Aortic Regurgitation
Mimics
• The entire constellation of diagnoses that underlies dyspnea, chest pain, and
other valvular diseases can mimic the presentation of aortic regurgitation.
Time-Dependent Interventions
• Time-dependent interventions in aortic regurgitation are necessary only when
acute aortic regurgitation is considered and cardiac and pulmonary function is
compromised. In such patients, urgent valve replacement may be a lifesaving
procedure.
• For chronic aortic regurgitation, there must be a well-planned and considered
approach to operative intervention.
Overall Principles ofTreatment
• Acute aortic regurgitation.
• In acute aortic regurgitation, urgent valve replacement is indicated.
Intravenous diuretics and vasodilators (such as sodium nitroprusside) may
be helpful as a bridge to surgery.
• In acute aortic regurgitation, intra-aortic balloon counterpulsation (IABP)
is contraindicated, as it may worsen the regurgitation. Intravenous betablockers are relatively contraindicated, as they may decrease cardiac output even further.
145
• Chronic aortic regurgitation.
• All patients diagnosed with aortic regurgitation, even those who are
asymptomatic, must have their systolic blood pressure controlled. Aortic
regurgitation is often associated with difcult-to-control systolic hypertension due to increased stroke volume. The goal should be less than 140mm
Hg. Most patients may benet from vasodilator therapy with ACE inhibitors, dihydropyridine calcium channel blockers, or hydralazine.
• Patients with early symptoms and mild dyspnea often also benet from the
addition of a diuretic.
• Surgery with aortic valve replacement is indicated for all symptomatic
patients with chronic aortic regurgitation.
• The optimal time for surgery seems to be after the onset of LV dysfunction
but before the development of symptoms. It is important to remember that
patients with chronic AR do not become symptomatic until after LV dysfunction develops.
146
• Appropriately timed surgery often may restore normal LV function.
However, surgery delayed for more than 1 year after the onset of LV dysfunction or symptoms often fails to restore normal LV function.
• If there are no indications for surgery, it is generally recommended that the
patient be followed up with exams and echocardiograms every 3–6 months.
• Indications for operation in the asymptomatic patient include:
• An LV ejection fraction <50 %
• An LV end-systolic dimension < 55mm or an end-diastolic dimension
<75mm
• A regurgitant fraction ≥50 %
• A regurgitant volume ≥ 60 mL
C. J. Rees et al.
Disease Course
• Patients with AR may remain asymptomatic for decades, but many patients
eventually require valve replacement surgery.
• Overall operative mortality is 3 %, but in the presence of prolonged LV dysfunction, mortality approaches 10 % and is then also associated with a late
mortality approaching 5 % per year from LV failure.
Related Evidence
Papers of particular interest have been highlighted as:
** Of key importance
Practice Guideline
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA,
O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM 3rd, Thomas JD; ACC/
AHA Task Force Members. 2014 AHA/ACC Guideline 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. 2014 Jun 10;129(23):e521-643. https://doi.org/10.1161/
CIR.0000000000000031. PMID: 24589853. http://www.ncbi.nlm.nih.gov/
pubmed/24589853 **
8 Aortic Regurgitation
147
Lancellotti P, Tribouilloy C, Hagendorff A, Moura L, Popescu BA, Agricola E,
Monin JL, Pierard LA, Badano L, Zamorano JL; European Association of
Echocardiography. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary
regurgitation (native valve disease). Eur J Echocardiogr. 2010 Apr;11(3):223-44.
https://doi.org/10.1093/ejechocard/jeq030. PMID: 20375260. http://www.ncbi.
nlm.nih.gov/pubmed/20375260 **
Review
Iung B, Vahanian A.Epidemiology of acquired valvular heart disease. Can J Cardiol.
2014 Sep;30(9):962-70. https://doi.org/10.1016/j.cjca.2014.03.022. PMID:
24986049. http://www.ncbi.nlm.nih.gov/pubmed/24986049 **
Prodromo J, D'Ancona G, Amaducci A, Pilato M. Aortic valve repair for aortic
insufciency: a review. J Cardiothorac Vasc Anesth. 2012 Oct;26(5):923-32.
https://doi.org/10.1053/j.jvca.2011.07.014. PMID: 22703946. http://www.ncbi.
nlm.nih.gov/pubmed/22703946 **
Hamirani YS, Dietl CA, Voyles W, Peralta M, Begay D, Raizada V. Acute aortic
regurgitation. Circulation. 2012 Aug 28;126(9):1121-6. https://doi.org/10.1161/
CIRCULATIONAHA.112.113993. PMID: 22927474. http://www.ncbi.nlm.nih.
gov/pubmed/22927474 **
Goldbarg SH, Halperin JL.Aortic regurgitation: disease progression and manage-
ment. Nat Clin Pract Cardiovasc Med. 2008 May;5(5):269-79. https://doi.
org/10.1038/ncpcardio1179. PMID: 18364707 http://www.ncbi.nlm.nih.gov/
pubmed/18364707 **
Bekeredjian R, Grayburn PA. Valvular heart disease: aortic regurgitation.
Circulation. 2005 Jul 5;112(1):125-34. PMID: 15998697.
nih.gov/pubmed/15998697 **
Enriquez-Sarano M, Tajik AJ.Clinical practice. Aortic regurgitation. N Engl J Med.
2004 Oct 7;351(15):1539-46. PMID: 15470217. http://www.ncbi.nlm.nih.gov/
pubmed/15470217 **
http://www.ncbi.nlm.
Use PubMed Clinical Queries to nd the most recent evidence. Use this search
strategy:
“Aortic Valve Insufciency”[Mesh] OR “Aortic Regurgitation”
Chapter 9
Aortic Stenosis
CharlesV.Pollack,Jr., MelissaPlatt, RichardM.Cantor,
andVictoriaG.Riese
Name andSynonyms
Aortic stenosis
Incidence/Epidemiology
The frequency of the causes of aortic valve disease varies geographically:
• Worldwide, rheumatic valve disease is the most common cause of aortic
stenosis
• In North America, calcied disease is the primary cause of aortic stenosis
C. V. Pollack,Jr. ()
Department of Emergency Medicine, Thomas Jefferson University,
Philadelphia, PA, USA
M. Platt
Department of Emergency, University of Louisville, Louisville, KY, USA
R. M. Cantor
Department of Emergency Medicine and Pediatrics, State University of NewYork Upstate
Medical University, Syracuse, NY, USA
V. G. Riese
Librarian Consultant, Eldersberg, MD, USA
C. V. Pollack, Jr. (ed.), Differential Diagnosis of Cardiopulmonary Disease,
https://doi.org/10.1007/978-3-319-63895-9_9
149© Springer Nature Switzerland AG 2019
150
C. V. Pollack, Jr. et al.
Differential Diagnosis
• The main issue to recognize is that the symptoms may be attributed to other
disease processes, and aortic stenosis can be missed in the acute setting
• Other diagnostic considerations include supravalvular aortic stenosis, congenital subvalvular aortic stenosis, and hypertrophic obstructive
cardiomyopathy.
Pathophysiology andEtiology
• Three primary causes of aortic stenosis:
• Congenital (unicuspid/bicuspid valve) with superimposed calcication
• Calcied disease of a trileaet aortic valve
• Rheumatic valve
Distribution of population according to aortic valve degeneration. Patients with
uninjured valve 49.5 %. Patients with aortic valve calcication and stenosis 25.5 %.
Patients with only valve calcications 25 %. [Fazio G, Caracciolo C, Barone R,
D’angelo L, Di Maggio R, Vernuccio F, Siragusa S.An unknown cause of aortic
valve stenosis: polycythemia vera. Journal of Thrombosis and Thrombolysis. 2013
Feb;35(2):282–5.] Caption from original
9 Aortic Stenosis
• Pathophysiology differs depending on the cause:
• Calcied disease occurs when lipid accumulation triggers an inammatory
response by various mediators. There is local production of protein that
promotes tissue calcication. Aortic stenosis occurs when the antegrade
velocity across an abnormal valve is at least 2.6 m/sec.
• Rheumatic valve disease causes fusion of the commissures between the
leaets leaving a small central opening.
151
152
C. V. Pollack, Jr. et al.
Two aortic valves seen at autopsy showing progression of calcic aortic stenosis. (a,
b) Radiograph and gross image of aortic valve from an 83-year-old female. This
valve shows mild calcication with small calcic deposits on aortic surface of cusps
and sparing of the free edge. (c, d) Histologic sections of cusps showing brotic
thickening and microscopic calcic deposits in the zona brosa (arrows). (e, f).
Radiograph and gross image of stenotic aortic valve from an 82-year-old female.
There is marked nodular calcication of the cusps with bulky deposits on the aortic
surface. (g, h) Histologic sections of the cusps show calcic nodules superimposed
on a brotic cusp with ulceration of the aortic surface (arrow). Note brotic thickening of the ventricular surface [Ladich E, Nakano M, Virmani R.Pathologic Findings
in Aortic Stenosis. In: Min JK, Berman DS, Leipsic J, editors. Multimodality
Imaging for Transcatheter Aortic Valve Replacement [Internet]. London: Springer
London; 2014 [cited 2015 Aug 27]. p.145–56. Available from: http://link.springer.
com/10.1007/978-1-4471-2798-7_11] Caption from original
9 Aortic Stenosis
153
Aortic stenosis (AS). The aortic valve orice is small; this may be a result of thickening of valve cusps, adhesion of cusp edges rendering separation between cusps
during systole limited and/or due to small valve annulus [Holmes KW, McCarville
MA.Aortic Stenosis. In: Abdulla R, editor. Heart Diseases in Children [Internet].
Boston, MA: Springer US; 2011 [cited 2015 Aug 27]. p.149–58. Available from:
http://link.springer.com/10.1007/978-1-4419-7994-0_11] Caption from original
Rheumatic heart disease: aortic stenosis. In this aortic valve, there is diffuse brosis
of the three cusps and fusion of the three commissures, producing a narrow central
orice [Buja LM, Cheong B.Cardiovascular Pathology. In: Krueger GRF, Buja LM,
editors. Atlas of Anatomic Pathology with Imaging [Internet]. London: Springer
London; 2013 [cited 2015 Aug 27]. p.43–104. Available from: http://link.springer.
com/10.1007/978-1-4471-2846-5_2] Caption from original
154
C. V. Pollack, Jr. et al.
Presentation
Typical/“Classic”
• Typically asymptomatic for a prolonged period of time. There is a wide degree
of outow obstruction that causes symptoms. On average, symptoms develop
once the aortic valve area is < 1.0cm2. The typical symptoms are heart failure,
syncope, and angina, but they reect late disease.
• In earlier disease dyspnea on exertion, decreased exercise tolerance, dizziness, and exertional angina are more common ndings.
Atypical
• Aortic stenosis can manifest as sudden cardiac death, atrial brillation, or
endocarditis.
Primary Differential Considerations
History andPhysical Exam
Findings that Conrm Diagnosis
• There is no single or combination of ndings that is sensitive or specic
enough to conrm the diagnosis of aortic stenosis.
Factors that Suggest Diagnosis
• The quality of the arterial pulse reects degrees of obstruction. This is often
described as “parvus and tardus,” meaning the pulse is weak and increases
slowly.
• There is a harsh systolic ejection murmur heard best at the second intercostal
space on the right. The murmur can be transmitted to the carotid arteries.
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