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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Moderate aortic regurgitation and stenosis (estimated aortic valve area 0.8–1.2 cm2)

GENERAL CONSIDERATIONS

  • In mixed aortic stenosis and regurgitation, 1 of the 2 lesions usually predominates and management is predicated on the dominant lesion

  • When both lesions are moderate, the degree of hemodynamic disturbance is considerably more than one would expect from either lesion alone

  • Moderate aortic regurgitation challenges the concentrically hypertrophied left ventricle from aortic stenosis by doing the following:

    • – Adding diastolic volume, which moves the ventricle up its steep pressure–volume curve

    • – Causing considerable diastolic pressure that is transmitted to the lungs, resulting in dyspnea and pulmonary congestion

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Dyspnea

  • Heart failure symptoms

  • Effort syncope

  • Angina pectoris

PHYSICAL EXAM FINDINGS

  • Enlarged left ventricular impulse

  • S3 or S4

  • Ejection sound if bicuspid valve

  • Diminished aortic S2

  • Typical harsh systolic ejection murmur and high-pitched diastolic decrescendo murmur in the aortic area

  • Signs of heart failure may be present

  • Peripheral signs of aortic regurgitation are usually absent because of the reduction in stroke volume from significant aortic stenosis

DIFFERENTIAL DIAGNOSIS

  • Severe aortic regurgitation with mild aortic stenosis

  • Severe aortic stenosis and mild regurgitation

  • The murmur of patent ductus arteriosus may be mimicked by moderate aortic stenosis/aortic regurgitation

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Brain natriuretic peptide test: elevated in heart failure

ELECTROCARDIOGRAPHY

  • ECG findings:

    • – Left ventricular hypertrophy

    • – Left atrial enlargement

IMAGING STUDIES

  • Chest x-ray findings:

    • – Enlarged left heart chambers

    • – Aortic valve calcification

    • – Pulmonary congestion

  • Echocardiography:

    • – Left ventricular hypertrophy and systolic function

    • – Left atrial enlargement

    • – Thickened aortic valve

    • – Dilated aorta

  • Doppler echocardiography:

    • – Continuous-wave Doppler measures the pressure gradient across the valve

    • – The continuity equation accurately determines valve area

    • – Color-flow Doppler assesses the severity of aortic regurgitation

DIAGNOSTIC PROCEDURES

  • Transesophageal echocardiography can image the aortic valve orifice area in difficult cases

  • Cardiac catheterization and angiography are frequently valuable:

    • – To confirm the severity of aortic stenosis and regurgitation

    • – To assess left ventricular diastolic performance

TREATMENT

CARDIOLOGY REFERRAL

  • Symptoms

  • Suspected moderately severe disease

HOSPITALIZATION CRITERIA

  • Evidence of heart failure

  • Suspicion of endocarditis

  • Significant arrhythmias

MEDICATIONS

  • Use diuretics for heart failure

  • Vasodilator drugs are relatively contraindicated because of the aortic stenosis

THERAPEUTIC PROCEDURES

  • Transcatheter aortic valve replacement relatively contraindicated because of the aortic regurgitation

SURGERY

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