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Chapter Summary

This chapter discusses three topics in the field of valvular heart disease: aortic regurgitation, mixed valvular heart disease, and prosthetic heart valves. Aortic regurgitation can be caused by a disease of the aortic valve, the ascending aorta, or both. Patients with chronic aortic regurgitation usually develop symptoms in late stages of the disease and should be followed-up closely. Although echocardiography is the main imaging modality for the evaluation of these patients, multimodality imaging should be considered in selected cases (see Fuster and Hurst's Central Illustration). Surgery is recommended in symptomatic patients and in asymptomatic patients with left ventricular dysfunction or marked dilatation. Mixed valvular heart disease is caused mainly by rheumatic and degenerative valvular disease, and has a complex pathophysiological and clinical expression. The evaluation and the management of patients with mixed valvular heart disease are challenging, which is why they should be followed-up in heart valve clinics. Prosthetic heart valve replacement is often the only effective treatment for patients affected by severe valvular heart disease. Mechanical valves require longterm anticoagulation whereas biological valves are associated with a higher risk of structural valve deterioration. Patients with prosthetic heart valves should be followed-up regularly for evaluation of prosthetic function and the occurrence of complications.

eFig 29-01 Chapter 29: Aortic Regurgitation, Mixed Valvular Heart Disease, and Heart Valve Prostheses



Aortic regurgitation (AR) results from inadequate closure of the aortic valve cusps. It may be caused by a disease modifying the aortic valve cusps (primary AR), by distortion or dilation of the aortic root and ascending aorta (secondary AR), or both (mixed AR).1,2 Severe acute AR leads to acute decompensated heart failure and needs prompt surgical intervention. Severe chronic AR leads to chronic left ventricle (LV) volume and pressure overload, progressive LV dilatation, systolic dysfunction, and if left untreated, to congestive heart failure. Presently, there is no medical treatment to prevent, slow down the progresion of, or cure severe AR. Surgery is the only treatment proven to decrease mortality.


In population-based echocardiographic studies, at least trace AR by color Doppler may exist even in healthy individuals.3 Depending on the definition used, patient age, and the characteristics of the subpopulation examined, the prevalence of AR (whether mild, moderate, or severe) has been estimated between 2% and 30%.3,4,5

According to a population-based cohort form the Framingham Heart Study, the prevalence of AR varies with age, gender, and disease severity.4 AR was unusual before the age of 50 and increased progressively later in life.4 It was more common in men than women, at least trace AR being reported in 13% of men and 8.5% of women.4 This could ...

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