Aortic regurgitation in young patients
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Congenital aortic insufficiency rarely occurs alone and is often associated with aortic stenosis or ventricular septal defect. Although it may occasionally be seen in adolescents and young adults with a bicuspid aortic valve, discrete subaortic obstruction, or prolapse of one of the aortic cusp into a ventricular septal defect. Turner syndrome, osteogenesis imperfecta, tetralogy of Fallot, and truncus arteriosus are other congenital disorders that are associated with aortic insufficiency in young patients.
Rheumatic heart disease is one of the important causes for acquired aortic insufficiency in young patients in developing countries. It can also occur following an episode of infective endocarditis or as a consequence of attempts to relieve aortic stenosis by either balloon valvuloplasty or surgical valvulotomy, or when the pulmonary artery is relocated in the aortic position during repair of transposition of great vessels.
Majority of young patients remain asymptomatic even with severe aortic insufficiency. Therefore these patients should be followed-up with serial echocardiographic assessment, including measurement of ventricular dimensions, volumes, and function. This could assist in determining the timing of surgical repair. Surgery is recommended for patients with symptoms of heart failure, dyspnoea on exertion with ischemic signs and symptoms, or at the first indication of a decline in left ventricular function. As in aortic stenosis, endocarditis prophylaxis is recommended for patients with aortic regurgitation.
Treatment
Medical therapy
Vasodilators are indicated in patients who have moderate to severe aortic insufficiency, are symptomatic or in those who have concurrent hypertension. ACE inhibitors with captopril in particular may be beneficial in children with partial improvement in ventricular dilation and hypertrophy. A study on benefits of ACE inhibitor in 20 children with aortic insufficiency showed that there was 28% reduction in regurgitant fraction[1].
Surgery is indicated in young patients with aortic insufficiency who are symptomatic or having left ventricular dysfunction (ejection fraction < 50%) or increased left ventricular end-diastolic/systolic dimension (body size should be taken into account). These are similar to indications for surgery in adults.
AHA/ACC guidelines for treatment of aortic insufficiency in adolescent or young adults [2]
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Class I
Class IIb
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The Ross Procedure
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References
- ↑ Alehan D, Ozkutlu S (1998). "Beneficial effects of 1-year captopril therapy in children with chronic aortic regurgitation who have no symptoms". American Heart Journal. 135 (4): 598–603. PMID 9539473. Retrieved 2011-04-07. Unknown parameter
|month=ignored (help) - ↑ Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS (2008). "2008 Focused update incorporated into the ACC/AHA 2006 guidelines 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 (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Retrieved 2011-04-07. Unknown parameter
|month=ignored (help)