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{{family tree | | | | | V01 | | | | | | | | | | | | | | | |V01= <div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms:''' <br>
 
❑ Most patients are asymptomatic <br> ❑ [[Dyspnea]] on exertion <br> ❑ Exertional [[dizziness]] <br> ❑ Exertional [[angina]] <br> ❑ [[Syncope]] <br> ❑ [[Chest pain]] <br> ❑ [[Palpitations]] </div> }}
{{Family tree | | | | | A01 | | | | | | | | | | | | | | | A01=<div style="float: left; text-align: left; line-height: 150% ">
{{family tree | | | | | |!| | | | | | | | | | | | | | | | }}
{{Family tree | | | | | Y01 | | | | | | | | | | | | | | | | Y01=<div style="float: left; text-align: Left; width:20em ">'''Inquire about past medical history:''' <br> ❑ Previously healthy <br> ❑ [[Cardiac disease]]: <br>
: ❑ [[Hypertension]]
: ❑ [[Bicuspid aortic valve]]
❑ [[Rheumatic fever]]  <br> ❑ [[Pulmonary disease]] </div> }}
{{family tree | | | | | |!| | | | | | | | | | | | | | | | }}
{{Family tree | | | | | A01 | | | | | | | | | | | | | | | A01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient''': <br>
❑ Heart rate <br> ❑ Pulses
: ❑ [[Pulsus parvus et tardus]]
❑ Cardiac palpation
: ❑ Apical impulse (due to [[LVH]])
: ❑ [[Systolic thrill]]
❑ Cardiac auscultation
: ❑ Crescendo-decrescendo [[heart murmur|systolic ejection murmur]] with ejection click
: ❑ Best heard at the upper right sternal border
: ❑ Bilateral radiation to the [[carotid arteries]]
: ❑ Murmur increases with: squatting, expiration
: ❑ Murmur decreases with [[valsalva maneuver]]
❑ Pulmonary auscultation:  search for [[rales]] (seen when [[congestive heart failure]] has developed)</div> }}
❑ Pulmonary auscultation:  search for [[rales]] (seen when [[congestive heart failure]] has developed)</div> }}
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{{Family tree | | | | | B01 | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: Left; width:20em "> '''Order imaging studies:''' <br> ❑ Order an [[echocardiography]], assess:
: ❑ Valve morphology
: ❑ Pressure gradient
: ❑ Aortic valve area
: ❑ Ejection fraction
: ❑ LV wall thickness and motility
❑ Order a [[CXR]], look for:
: ❑ [[Cardiomegaly]]
: ❑ Valve calcification
: ❑ Dilatation of ascending aorta
: ❑ Pulmonary congestion
❑ Order a [[ECG]], look for:
: ❑ [[LVH]]
: ❑ Left [[atrium enlargement]]
: ❑ [[LBBB]]
: ❑ [[AF]] (in late disease) </div>}}
{{family tree | | | | | |!| | | | | | | | | | | | | | | | }}
{{Family tree | | | | | Z01 | | | | | | | | | | | | | | Z01=<div style="float: left; text-align: Left; width:20em ">'''Interpret results from [[echocardiography|echo]]'''</div>}}
{{Family tree | |,|-|-|-|+|-|-|-|-|-|-|-|.| | | | | | | |}}
{{Family tree | C01 | | C02 | | | | | | C03 | | | | | | |C01=<div style="float: left; text-align: left; width: 12em line-height: 150% "> '''No stenosis''' ([[Aortic stenosis stages|Stage A]]) <br> ❑ Valve area 2.5-3.5 cm² <br> ❑ No pressure gradient </div> | C02=<div style="float: left; text-align: left; line-height: 150% ">'''Mild to moderate stenosis''' ([[Aortic stenosis stages|Stage B]]) <br> '''Mild:''' <br> ❑ Valve area 1.5-2.5 cm² <br> ❑ Pressure gradient ≤ 25 mmHg <br> '''Moderate:''' <br> ❑ Valve area 1.0-1.5 cm² <br> ❑ Pressure gradient 25-40 mmHg </div> | C03= <div style="float: left; text-align: left; width: 15em; line-height: 150% ">'''Severe stenosis''' <br> ❑ Valve area ≤ 1.0 cm² <br> ❑ Pressure gradient ≥ 40 mmHg </div>}}
{{family tree | |!| | | |!| | | | | |,|-|^|-|-|-|-|.| | | |}}
{{Family tree | D01 | | D02 | | | | D03 | | | | | D04 | | | |D01=<div style="float: left; text-align: left; width: 12em; line-height: 150% "> ❑ Normal valve <br> ❑ Bicuspid valve <br> ❑ Sclerotic valve </div>| D02=<div style="float: left; text-align: left; line-height: 150% "> '''Perform a periodic echocardiogram''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]]) <br> ❑ Every 3 -5 yrs for mild stenosis <br> ❑  Every 1 - 2 yrs for moderate stenosis </div> | D03= '''Patient asymptomatic''' <br> ([[Aortic stenosis stages|Stage C]])| D04= '''Patient symptomatic''' <br> ([[Aortic stenosis stages|Stage D]]) }}
{{family tree | |!| | | |:| | | |,|-|^|-|.| | | |,|^|-|.| }}
{{Family tree | E01 | | E00 | | E02 | | E03 | |E04| |E05| | E01= <div style="float: left; text-align: left; width: 12em; line-height: 150% "> ❑ '''Control hypertension''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]])  </div>| E00= <div style=" text-align: left"> If patient undergoes another cardiac surgery: <br> ❑ '''Schedule for [[AVR]]''' ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: C]]) </div>|E02= '''Normal LVEF''' <br> ([[Aortic stenosis stages|Stage C1]])| E03= '''LVEF < 50%''' <br> ([[Aortic stenosis stages|Stage C2]]) | E04= '''High gradient (ΔP ≥ 40 mmHg)''' <br> ([[Aortic stenosis stages|Stage D1]]) | E05=<div style="float: left; text-align: left; width: 20 em "> '''Low gradient (ΔP ≤ 40 mmHg)''' <br> ❑ Normal LVEF ([[Aortic stenosis stages|Stage D2]]) <br> ❑ LVEF < 50% ([[Aortic stenosis stages|Stage D3]]) </div> }}
{{family tree | | | | | | | | | |!| | | |`|v|-|'| | | |!| | | | }}
{{Family tree | | | | | | | |  F01 | | | F02 | | | | F03 | | |F01= <div style=" text-align:left; width: 15em"> '''Perform a periodic echocardiogram every 6 - 12 months''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: B]]) </div>  | F02= '''Schedule for [[AVR]]''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: A]]) | F03=<div style="float: left; text-align: left; width: 18em; line-height: 150% "> '''Schedule for [[AVR]]''' ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B-C]])</div>}}
{{family tree | | | | | | | | | |!| | | | | | | | | | | | | | }}
{{family tree | | | | | | | |  G01 | | | | | | | | | | | | | |G01= <div style=" text-align:left; width: 15em">  If aortic velocity ≥ 5 m/s or decrease in exercise tolerance: <br> ❑ '''Schedule for [[AVR]]''' ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]]) </div>}}


{{familytree/end}}
<br>
<br>
'''LVH''': Left ventricle hypertrophy; '''CXR''': Chest x-ray; '''ECG''': Electrocardiogram; '''LBBB''': Left bundle branch block; '''AF''': Atrial fibrillation; '''AVR''': Aortic valve replacement; '''VHD''': Valve heart disease; '''TAVR''': Transcatheter aortic valve replacement


==Choice of intervention==


Shown below is an algorithm summarizing the choice of the intervention to [[aortic stenosis]] <ref name="2014 AHA">{{Cite web  | last = | first = | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.full.pdf+html | publisher =  | date =  | accessdate = 4 March 2014 }}</ref>
==Do's==


{{Family tree/start}}
❑
{{family tree | | | | | | | A01 | | | | | | | | A01= '''Patient scheduled for [[AVR]]'''  }}
{{family tree | | | |,|-|-|-|^|-|-|-|.| | | | | }}
{{family tree | | | B01 | | | | | | B02 | | | | B01= '''High risk'''<ref name="Ben-DorPichard2010">{{cite journal|last1=Ben-Dor|first1=I.|last2=Pichard|first2=A. D.|last3=Gonzalez|first3=M. A.|last4=Weissman|first4=G.|last5=Li|first5=Y.|last6=Goldstein|first6=S. A.|last7=Okubagzi|first7=P.|last8=Syed|first8=A. I.|last9=Maluenda|first9=G.|last10=Collins|first10=S. D.|last11=Delhaye|first11=C.|last12=Wakabayashi|first12=K.|last13=Gaglia|first13=M. A.|last14=Torguson|first14=R.|last15=Xue|first15=Z.|last16=Satler|first16=L. F.|last17=Suddath|first17=W. O.|last18=Kent|first18=K. M.|last19=Lindsay|first19=J.|last20=Waksman|first20=R.|title=Correlates and Causes of Death in Patients With Severe Symptomatic Aortic Stenosis Who Are Not Eligible to Participate in a Clinical Trial of Transcatheter Aortic Valve Implantation|journal=Circulation|volume=122|issue=11_suppl_1|year=2010|pages=S37–S42|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.109.926873}}</ref>


----
❑ STS Score<ref name="STS">{{Cite web  | last =  | first =  | title = Online STS Risk Calculator | url = http://riskcalc.sts.org/ | publisher =  | date =  | accessdate = 7 March 2014 }}</ref> > 10 <br> ❑ EuroScore<ref name="www.euroscore.org">{{Cite web  | last =  | first =  | title = http://www.euroscore.org/calc.html | url = http://www.euroscore.org/calc.html | publisher =  | date =  | accessdate = 7 March 2014 }}</ref> > 20| B02= '''Low to moderate risk'''<ref name="Ben-DorPichard2010">{{cite journal|last1=Ben-Dor|first1=I.|last2=Pichard|first2=A. D.|last3=Gonzalez|first3=M. A.|last4=Weissman|first4=G.|last5=Li|first5=Y.|last6=Goldstein|first6=S. A.|last7=Okubagzi|first7=P.|last8=Syed|first8=A. I.|last9=Maluenda|first9=G.|last10=Collins|first10=S. D.|last11=Delhaye|first11=C.|last12=Wakabayashi|first12=K.|last13=Gaglia|first13=M. A.|last14=Torguson|first14=R.|last15=Xue|first15=Z.|last16=Satler|first16=L. F.|last17=Suddath|first17=W. O.|last18=Kent|first18=K. M.|last19=Lindsay|first19=J.|last20=Waksman|first20=R.|title=Correlates and Causes of Death in Patients With Severe Symptomatic Aortic Stenosis Who Are Not Eligible to Participate in a Clinical Trial of Transcatheter Aortic Valve Implantation|journal=Circulation|volume=122|issue=11_suppl_1|year=2010|pages=S37–S42|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.109.926873}}</ref>
----
❑ STS Score<ref name="STS">{{Cite web  | last =  | first =  | title = Online STS Risk Calculator | url = http://riskcalc.sts.org/ | publisher =  | date =  | accessdate = 7 March 2014 }}</ref> < 10 <br> ❑ EuroScore<ref name="www.euroscore.org">{{Cite web  | last =  | first =  | title = http://www.euroscore.org/calc.html | url = http://www.euroscore.org/calc.html | publisher =  | date =  | accessdate = 7 March 2014 }}</ref> < 20 }}
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{{family tree | | | C01 | | | | | | C02 | | | | | C01=<div style=" text-align: left"> ❑ A multidisciplinary group of physicians with expertise in VHD,<br> cardiac imaging, interventional cardiology, cardiac anesthesia, and <br> cardiac surgery should decide intervention (Surgical [[AVR]] or <br> [[transcatheter aortic valve implantation|TAVR]]) ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: C]]) <br> ❑ Schedule for [[transcatheter aortic valve implantation|'''TAVR''']] ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])<ref name="2014 AHA">{{Cite web  | last =  | first =  | title = 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary | url = http://circ.ahajournals.org/content/early/2014/02/27/CIR.0000000000000029.full.pdf+html | publisher =  | date =  | accessdate = 4 March 2014 }}</ref>  <ref name="SmithLeon2011">{{cite journal|last1=Smith|first1=Craig R.|last2=Leon|first2=Martin B.|last3=Mack|first3=Michael J.|last4=Miller|first4=D. Craig|last5=Moses|first5=Jeffrey W.|last6=Svensson|first6=Lars G.|last7=Tuzcu|first7=E. Murat|last8=Webb|first8=John G.|last9=Fontana|first9=Gregory P.|last10=Makkar|first10=Raj R.|last11=Williams|first11=Mathew|last12=Dewey|first12=Todd|last13=Kapadia|first13=Samir|last14=Babaliaros|first14=Vasilis|last15=Thourani|first15=Vinod H.|last16=Corso|first16=Paul|last17=Pichard|first17=Augusto D.|last18=Bavaria|first18=Joseph E.|last19=Herrmann|first19=Howard C.|last20=Akin|first20=Jodi J.|last21=Anderson|first21=William N.|last22=Wang|first22=Duolao|last23=Pocock|first23=Stuart J.|title=Transcatheter versus Surgical Aortic-Valve Replacement in High-Risk Patients|journal=New England Journal of Medicine|volume=364|issue=23|year=2011|pages=2187–2198|issn=0028-4793|doi=10.1056/NEJMoa1103510}}</ref></div> | C02= ❑ Schedule for '''surgical [[AVR]]''' ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: A]]) }}


{{familytree/end}}<br>
==Don'ts==
'''STS''': Society of Thoracic Surgeons
❑
 
==Type of valve and anticoagulation therapy==
{{Family tree/start}}
{{Family tree | | | | | | | A01 | | | | | A01= ❑ '''Age of patient?''' <br> ❑ '''Anti-coagulation contraindications?''' }}
{{Family tree | | | |,|-|-|-|^|-|-|-|.| | |}}
{{Family tree | | | B01 | | | | | | B02 | | |  B01=<div style=" text-align:left"> ❑ Patients ≤ 70 years old ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])</div>| B02= <div style=" text-align:left"> ❑ Patients with anticoagulant therapy contraindications <br> ([[ACC AHA guidelines classification scheme|Class I; Level of Evidence: C]]) <br> ❑ Patients ≥ 70 years old ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]])</div> }}
{{Family tree | | | |!| | | | | | | |!| | | }}
{{Family tree | | | C01 | | | | | | C02 | | | C01= '''Mechanical Prosthesis'''| C02= '''Bioprosthesis'''}}
{{Family tree | |,|-|^|-|.| | | |,|-|^|-|.| }}
{{Family tree | D01 | | D02 | | D03 | | D04 | | D01= Patient with risk factors | D02= Patient without risk factors| D03= [[AVR]] | D04= [[Transcatheter aortic valve implantation|TAVR]]}}
{{Family tree | |!| | | |!| | | |!| | | |!| | | }}
{{Family tree | E01 | | E02 | | E03 | | E04 | | E01=<div style=" text-align:left"> ❑ Give [[warfarin]] to achieve INR of 3.0 <br> ❑ Give [[aspirin]] 75-100 mg/d <br> ❑ Both long term </div> | E02=<div style=" text-align:left"> ❑ Give [[warfarin]] to achieve INR of 2.5 <br> ❑ Give [[aspirin]] 75-100 mg/d <br> ❑  Both long term </div>| E03= <div style=" text-align:left">❑ Give [[warfarin]] to achieve INR of 2.5 for 3 months  <br> ❑ Then give [[aspirin]] 75-100 mg/d long term </div>| E04=<div style=" text-align:left"> ❑ Give [[clopidrogel]] 75 mg/d <br> ❑ Give [[aspirin]] 75-100 mg/d <br> ❑ Both for 6 months </div> }}
 
{{Family tree/end}}
<br>
❑ Either a bioprosthetic or mechanical valve is reasonable in patients between 60 and 70 years of age. ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]]).
 
==Do's==


❑  Give [[ACE inhibitors]] to control [[hypertension]] in patients with asymptomatic [[aortic stenosis]]. <ref name="Chambers2005">{{cite journal|last1=Chambers|first1=J.|title=The left ventricle in aortic stenosis: evidence for the use of ACE inhibitors|journal=Heart|volume=92|issue=3|year=2005|pages=420–423|issn=1355-6037|doi=10.1136/hrt.2005.074112}}</ref> <br>
❑ Exercise testing in asymptomatic patients with AS may be considered to elicit exercise-induced symptoms and abnormal blood pressure responses ([[ACC AHA guidelines classification scheme|Class IIb; Level of Evidence: B]]). <br>
❑ Dobutamine stress echocardiography is reasonable to evaluate patients with low-flow/low-gradient AS and LV dysfunction ([[Aortic stenosis stages|Stage D3]]) ([[ACC AHA guidelines classification scheme|Class IIa; Level of Evidence: B]]) <br>
❑ Aortic balloon valvotomy might be reasonable as a bridge to surgery in hemodynamically unstable adult patients with AS who are at high risk for [[AVR]] or  cannot be performed because of serious comorbid conditions.([[ACC AHA guidelines classification scheme|Class IIb; Level of Evidence: C]]). <br>
==Don'ts==
❑ Do not perform a [[stress test]] in a symptomatic patient with [[aortic stenosis stages|stage D]] [[aortic stenosis]] ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: B]]). <br>
❑ Do not give [[statins]] to prevent hemodynamic progression in patients with mild to moderate [[calcific aortic valve disease]] ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: A]]). <br>
❑  [[Transcatheter aortic valve implantation|TAVR]] is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of [[AS]] ([[ACC AHA guidelines classification scheme|Class III; Level of Evidence: B]])<br>
❑ Do not give [[vasodilators]] to patients with severe [[AS]] as they may cause severe [[hypotension]]. <br>
❑ [[Endocarditis prophylaxis]] is not indicated in patients with [[AR]]. <ref name="Bonow-2008">{{Cite journal  | last1 = Bonow | first1 = RO. | last2 = Carabello | first2 = BA. | last3 = Chatterjee | first3 = K. | last4 = de Leon | first4 = AC. | last5 = Faxon | first5 = DP. | last6 = Freed | first6 = MD. | last7 = Gaasch | first7 = WH. | last8 = Lytle | first8 = BW. | last9 = Nishimura | first9 = RA. | title = 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. | journal = Circulation | volume = 118 | issue = 15 | pages = e523-661 | month = Oct | year = 2008 | doi = 10.1161/CIRCULATIONAHA.108.190748 | PMID = 18820172 }}</ref>


==References==
==References==

Revision as of 15:56, 11 March 2014


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Definition

Aortic insufficiency refers to the retrograde or backward flow of blood from the aorta into the left ventricle during diastole.[1][2][3][4]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

  • [[

Common Causes

  • [[
  • [[
  • [[
  • [[

Management

Shown below is an algorithm summarizing the approach to aortic insufficiency [5][6]



Do's

❑


Don'ts

❑


References

  1. ↑ Connolly HM, Crary JL, McGoon MD; et al. (1997). "Valvular heart disease associated with fenfluramine-phentermine". N. Engl. J. Med. 337 (9): 581–8. doi:10.1056/NEJM199708283370901. PMID 9271479.
  2. ↑ Weissman NJ (2001). "Appetite suppressants and valvular heart disease". Am. J. Med. Sci. 321 (4): 285–91. doi:10.1097/00000441-200104000-00008. PMID 11307869.
  3. ↑ Schade R, Andersohn F, Suissa S, Haverkamp W, Garbe E (2007). "Dopamine agonists and the risk of cardiac-valve regurgitation". N. Engl. J. Med. 356 (1): 29–38. doi:10.1056/NEJMoa062222. PMID 17202453.
  4. ↑ Zanettini R, Antonini A, Gatto G, Gentile R, Tesei S, Pezzoli G (2007). "Valvular heart disease and the use of dopamine agonists for Parkinson's disease". N. Engl. J. Med. 356 (1): 39–46. doi:10.1056/NEJMoa054830. PMID 17202454.
  5. ↑ "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.
  6. ↑ Bonow, R. O.; Carabello, B. A.; Chatterjee, K.; de Leon, A. C.; Faxon, D. P.; Freed, M. D.; Gaasch, W. H.; Lytle, B. W.; Nishimura, R. A.; O'Gara, P. T.; O'Rourke, R. A.; Otto, C. M.; Shah, P. M.; Shanewise, J. S. (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–e661. doi:10.1161/CIRCULATIONAHA.108.190748. ISSN 0009-7322.


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❑ Pulmonary auscultation: search for rales (seen when congestive heart failure has developed)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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