Aortic Regurgitation Follow-up

  • Author: Stanley S Wang, MD, JD, MPH; Chief Editor: Richard A Lange, MD   more...
 
Updated: Jun 2, 2010
 

Further Inpatient Care

Inpatient care is required for most patients with acute severe aortic regurgitation (AR), particularly with symptoms or evidence of hemodynamic decompensation. Patients with chronic severe AR may be followed as inpatients or outpatients, depending on the stage of their disease and severity of their symptoms and LV dysfunction.

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Further Outpatient Care

Asymptomatic patients with chronic severe AR require ongoing clinical surveillance with periodic echocardiography because in many cases, significant LV dysfunction may arise even before the patient becomes symptomatic.

The recommended frequency of clinical evaluation is based on the stability of the left ventricular end-systolic dimensions (ESD) and end-diastolic dimensions (EDD) as listed below. After the initial study, clinical evaluation and repeat echocardiogram are recommended in 3 months. Subsequent follow-up is based on the results of the 2 evaluations.

  • For patients with ESD < 45 mm or EDD < 60 mm and stable dimensions, clinical evaluation is recommended every 6-12 months and repeat echocardiography is recommended every 12 months.
  • For patients with ESD < 45 mm or EDD < 60 mm and increasing dimensions, clinical evaluation and repeat echocardiography are recommended in 3 months.
  • For patients with ESD 45-50 mm or EDD 60-70 mm and stable dimensions, clinical evaluation is recommended every 6 months and repeat echocardiography is recommended every 12 months.
  • For patients with ESD 45-50 mm or EDD 60-70 mm and increasing dimensions, clinical evaluation and repeat echocardiography are recommended in 3 months.
  • For patients with ESD 50-55 mm or EDD 70-75 mm and stable dimensions, clinical evaluation and repeat echocardiography are recommended every 6 months.
  • For patients with ESD 50-55 mm or EDD 70-75 mm and increasing dimensions, clinical evaluation and repeat echocardiography are recommended in 3 months.
  • For patients with ESD >55 mm or EDD >75 mm, surgery is recommended.
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Inpatient & Outpatient Medications

Vasodilator therapy may be used on an inpatient or outpatient basis under the conditions listed above as recommended under current ACC/AHA guidelines. All patients with artificial heart valves should receive antibiotic prophylaxis prior to dental procedures. For antithrombotic therapy, all patients with artificial heart valves should receive daily aspirin, and many should also receive oral anticoagulation therapy with warfarin according to the ACC/AHA guidelines.[5]

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Transfer

For patients who are hospitalized for severe AR in facilities without appropriate cardiovascular and surgical expertise, transfer may be justified to optimize clinical outcomes. For outpatients with stable but severe AR, longitudinal care by a cardiologist with appropriate expertise is recommended.

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Deterrence/Prevention

Recommendations regarding exercise and antibiotic prophylaxis have been discussed above.

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Complications

Left untreated, acute severe AR is likely to lead to considerable morbidity and mortality from either the underlying cause (typically infective endocarditis or aortic dissection) or from hemodynamic decompensation of the LV.

Potential complications in patients with chronic severe AR include progressive LV dysfunction and dilation, congestive heart failure, myocardial ischemia, arrhythmia, and sudden death. Additional complications may arise as a result of the patient's underlying condition (such as aortic root dissection in a patient with a bicuspid aortic valve and a severely dilated aortic root).

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Prognosis

The prognosis for patients with severe AR depends on the presence or absence of LV dysfunction and symptoms, as follows:[5]

  • In asymptomatic patients with normal EF
    • Rate of progression to symptoms or LV dysfunction = < 6% per year
    • Rate of progression to asymptomatic LV dysfunction = < 3.5% per year
    • Rate of sudden death = less than 0.2% per year
  • In asymptomatic patients with decreased EF, rate of progression to symptoms = >25% per year.
  • In symptomatic patients, mortality rate = >10% per year.

Again, the strongest predictors of outcome are echocardiographic parameters (EF and LV end-systolic dimension), underscoring the crucial role of serial echocardiography in the management of patients with severe AR.

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Patient Education

The current ACC/AHA guidelines for valvular heart disease, including for AR, are available to the public online for free.[5] Additionally, educational and support organizations exist for many of the underlying conditions, such as National Marfan Foundation and Bicuspid Aortic Foundation.

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Contributor Information and Disclosures
Author

Stanley S Wang, MD, JD, MPH  Clinical Cardiologist, Austin Heart South; Assistant Professor of Medicine (Adjunct), University of North Carolina School of Medicine

Stanley S Wang, MD, JD, MPH is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, American Stroke Association, and Texas Medical Association

Disclosure: Abbott Labs Honoraria Speaking and teaching

Specialty Editor Board

Martin Keane, MD, FACC, FAHA  Associate Professor, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania School of Medicine

Martin Keane, MD, FACC, FAHA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Heart Association, American Society of Echocardiography, Pennsylvania Medical Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Steven J Compton, MD, FACC, FACP  Director of Cardiac Electrophysiology, Alaska Heart Institute, Providence and Alaska Regional Hospitals

Steven J Compton, MD, FACC, FACP is a member of the following medical societies: Alaska State Medical Association, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, and Heart Rhythm Society

Disclosure: Nothing to disclose.

Amer Suleman, MD  Private Practice

Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions

Disclosure: Nothing to disclose.

Chief Editor

Richard A Lange, MD  Professor and Executive Vice Chairman, Department of Medicine, Director, Office of Educational Programs, University of Texas Health Science Center at San Antonio

Richard A Lange, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, and Association of Subspecialty Professors

Disclosure: Nothing to disclose.

References

  1. Maurer G. Aortic regurgitation. Heart. Jul 2006;92(7):994-1000. [Medline].

  2. Singh JP, Evans JC, Levy D, et al. Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study). Am J Cardiol. Mar 15 1999;83(6):897-902. [Medline].

  3. Feldman T. Rheumatic heart disease. Curr Opin Cardiol. Mar 1996;11(2):126-30. [Medline].

  4. Dujardin KS, Enriquez-Sarano M, Schaff HV, Bailey KR, Seward JB, Tajik AJ. Mortality and morbidity of aortic regurgitation in clinical practice. A long-term follow-up study. Circulation. Apr 13 1999;99(14):1851-7. [Medline].

  5. Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD. 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. J Am Coll Cardiol. Sep 23 2008;52(13):e1-142. [Medline]. [Full Text].

  6. Keane MG, Pyeritz RE. Medical management of Marfan syndrome. Circulation. May 27 2008;117(21):2802-13. [Medline]. [Full Text].

  7. Ortiz JT, Shin DD, Rajamannan NM. Approach to the patient with bicuspid aortic valve and ascending aorta aneurysm. Curr Treat Options Cardiovasc Med. Dec 2006;8(6):461-7. [Medline].

  8. Friedman T, Mani A, Elefteriades JA. Bicuspid aortic valve: clinical approach and scientific review of a common clinical entity. Expert Rev Cardiovasc Ther. Feb 2008;6(2):235-48. [Medline].

  9. Palazzi C, D' Angelo S, Lubrano E, Olivieri I. Aortic involvement in ankylosing spondylitis. Clin Exp Rheumatol. May-Jun 2008;26(3 Suppl 49):S131-4. [Medline].

  10. Schirmer M, Weidinger F, Sandhofer A, Gschwendtner A, Wiedermann C. Valvular disease and myocardial infarctions in a patient with Behçet disease. J Clin Rheumatol. Oct 2003;9(5):316-20. [Medline].

  11. Eberhardt RT, Dhadly M. Giant cell arteritis: diagnosis, management, and cardiovascular implications. Cardiol Rev. Mar-Apr 2007;15(2):55-61. [Medline].

  12. Chand EM, Freant LJ, Rubin JW. Aortic valve rheumatoid nodules producing clinical aortic regurgitation and a review of the literature. Cardiovasc Pathol. Nov-Dec 1999;8(6):333-8. [Medline].

  13. Jain D, Halushka MK. Cardiac pathology of systemic lupus erythematosus. J Clin Pathol. Jul 2009;62(7):584-92. [Medline].

  14. Moyssakis I, Tektonidou MG, Vasilliou VA, Samarkos M, Votteas V, Moutsopoulos HM. Libman-Sacks endocarditis in systemic lupus erythematosus: prevalence, associations, and evolution. Am J Med. Jul 2007;120(7):636-42. [Medline].

  15. Lee JL, Naguwa SM, Cheema GS, Gershwin ME. Revisiting Libman-Sacks endocarditis: a historical review and update. Clin Rev Allergy Immunol. Jun 2009;36(2-3):126-30. [Medline].

  16. Adachi O, Saiki Y, Akasaka J, Oda K, Iguchi A, Tabayashi K. Surgical management of aortic regurgitation associated with takayasu arteritis and other forms of aortitis. Ann Thorac Surg. Dec 2007;84(6):1950-3. [Medline].

  17. Jeserich M, Ihling C, Holubarsch C. Aortic valve endocarditis with Whipple disease. Ann Intern Med. Jun 1 1997;126(11):920. [Medline].

  18. Gaztanaga J, Pizarro G, Sanz J. Evaluation of cardiac valves using multidetector CT. Cardiol Clin. Nov 2009;27(4):633-44. [Medline].

  19. Morello A, Gelfand EV. Cardiovascular magnetic resonance imaging for valvular heart disease. Curr Heart Fail Rep. Sep 2009;6(3):160-6. [Medline].

  20. Myerson SG. Valvular and hemodynamic assessment with CMR. Heart Fail Clin. Jul 2009;5(3):389-400, vi-vii. [Medline].

  21. Picano E, Pibarot P, Lancellotti P, Monin JL, Bonow RO. The emerging role of exercise testing and stress echocardiography in valvular heart disease. J Am Coll Cardiol. Dec 8 2009;54(24):2251-60. [Medline].

  22. Bekeredjian R, Grayburn PA. Valvular heart disease: aortic regurgitation. Circulation. Jul 5 2005;112(1):125-34. [Medline].

  23. Bhudia SK, McCarthy PM, Kumpati GS, Helou J, Hoercher KJ, Rajeswaran J, et al. Improved outcomes after aortic valve surgery for chronic aortic regurgitation with severe left ventricular dysfunction. J Am Coll Cardiol. Apr 3 2007;49(13):1465-71. [Medline].

  24. Rahimtoola SH. Choice of Prosthetic Heart Valve in Adults An Update. J Am Coll Cardiol. Jun 1 2010;55(22):2413-2426. [Medline].

  25. Sampat U, Varadarajan P, Turk R, Kamath A, Khandhar S, Pai RG. Effect of beta-blocker therapy on survival in patients with severe aortic regurgitation results from a cohort of 756 patients. J Am Coll Cardiol. Jul 28 2009;54(5):452-7. [Medline].

  26. Bostwick DG, Bensch KG, Burke JS, Billingham ME, Miller DC, Smith JC, et al. Whipple's disease presenting as aortic insufficiency. N Engl J Med. Oct 22 1981;305(17):995-8. [Medline].

  27. Goldbarg SH, Halperin JL. Aortic regurgitation: disease progression and management. Nat Clin Pract Cardiovasc Med. May 2008;5(5):269-79. [Medline].

 
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