eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology
Aortic Valve Insufficiency: Follow-up
Updated: Oct 26, 2009
Follow-up
Further Inpatient Care
- Most inpatient follow-up care relates to symptomatic aortic valve insufficiency that has warranted valve replacement.
- Aortic valve replacement for aortic regurgitation (AR), in patients with severe aortic regurgitation and symptoms of heart failure, improves the patient's survival rate and quality of life.
- In asymptomatic patients with impaired left ventricular (LV) function, valve replacement prevents a decrease in LV function.
- In asymptomatic patients, if surgery is performed soon after recognition of ventricular dysfunction, the postoperative outcome is good in terms of survival rate and restoration of a normal ventricular function.
Further Outpatient Care
- Patients with chronic aortic regurgitation usually do not become symptomatic until after the development of myocardial dysfunction.
- Surgical treatment often does not restore normal LV function.
- In patients with severe aortic regurgitation, careful clinical follow-up and noninvasive testing with echocardiography at approximately 6-month intervals are necessary for correct timing of surgical intervention (after the onset of LV dysfunction but before the development of severe symptoms).
- Lack of symptoms and normal LV function indicate that surgery can be delayed.
- Surgery should be considered for asymptomatic patients with progressive LV dysfunction and an LV ejection fraction less than 0.50, an LV or end-systolic volume higher than 55 mL/m2, or an end-systolic diameter longer than 55 mm.
- An echocardiographic evaluation should be performed in asymptomatic patients with known aortic regurgitation, looking for signs of development of LV dysfunction.
Deterrence/Prevention
- Prevention of infective endocarditis is of major importance. Studious attention to dental hygiene is of paramount importance in reducing the chances of an endocarditis episode.
- The goal is to preserve normal LV function and volume and to prevent development of symptoms of heart failure.
Prognosis
- The prognosis largely depends on how accurately the aortic valve insufficiency is characterized and how well the aortic valve insufficiency is then managed.
Patient Education
- Because of the complexity of management, detailed education is required for parents and, if applicable, the patient.
Miscellaneous
Medicolegal Pitfalls
- The timing of surgery for severe aortic valve insufficiency is among the most challenging problems facing the cardiologist. Errors in judgment are frequent and may lead to litigation.
Special Concerns
- Pregnancy
- Less than 1% of all pregnancies are affected by any cardiac disease; however, cardiac disease and hemodynamic changes during pregnancy can be significant causes of morbidity and mortality in the mother and can affect the outcome of the pregnancy.
- As with mitral regurgitation, the negative consequences of chronic aortic regurgitation (AR) during pregnancy are minimal. This may be because of reduced systemic vascular resistance (SVR) and an increased heart rate, which leads to a short time of diastole. If the patient becomes symptomatic, medications such as diuretics, digoxin, and hydralazine for left ventricle (LV) afterload reduction can be used safely.
- Physiologic changes in the cardiovascular system during pregnancy can be determined by the increased blood volume, increased heart rate, increased stroke volume, decreased systemic vascular resistance, and increased LV ejection fraction.
- Pregnancy is a state of volume expansion. Midpregnancy is the time of maximal volume expansion rate. This volume expansion does not include a significant increase in hemoglobin production; as a result, a physiologic anemia of pregnancy develops, which is related to dilution and expansion of plasma volume in relation to hematocrit level. Therapy with iron may help improve the hematocrit level. Estrogen-mediated stimulation of the renin-angiotensin system and subsequent activity of aldosterone in increased sodium reabsorption from the kidney tubules are thought to be mediators of the increased retention of water and subsequent volume increase.
- The heart rate increases during pregnancy. This increase is more notable as pregnancy progresses and can be as much as 20% higher than baseline.
- Stroke volume increases during pregnancy. This increase is less notable in the first few weeks of pregnancy and can be as much as 40% higher than baseline.
- Systemic vascular resistance decreases during pregnancy to as much as 30-40% lower than baseline.
- LV ejection fraction increases slightly during pregnancy, from 5-10% higher than baseline.
- Cardiac output (ie, product of heart rate and stroke volume) increases during pregnancy because heart rate and stroke volume are also evaluated.
- Blood pressure (ie, product of cardiac output and systemic vascular resistance) is basically unchanged during pregnancy. As cardiac output increases and systemic vascular resistance decreases, the product is only minimally affected. This is true for systolic and diastolic blood pressure.
- Physiologic changes in the cardiovascular system during labor can be determined by changes related to anxiety, stress of pregnancy, and pain of labor.
- Increased oxygen consumption up to 3-fold to 4-fold
- Progressive increase in cardiac output
- Increase in blood pressure
- Further increase in blood pressure during the active phase of labor
- Adequate control during pain and anxiety during labor can be important in minimizing hemodynamic changes of labor.
- Cesarean delivery
- Advantages
- Less anxiety
- Less pain
- Less fluctuation in blood pressure
- Disadvantages
- Excessive blood loss
- Effect of general anesthesia
- Stress of intubation and extubation
- Postanesthesia recovery
- Adequacy of analgesia
- Advantages
- Postpartum hemodynamic changes
- Venous return is increased (compression release from the inferior vena cava).
- Autotransfusion occurs from the uterus to systemic circulation.
- In time, most hemodynamic changes return to normal. Cardiac output and heart rate return to prelabor values within an hour. By 24 hours, blood pressure and stroke volume normalize.
The authors and editors of eMedicine gratefully acknowledge the contributions of Samuel Ritter, MD, to the original writing and development of this article.
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Further Reading
Keywords
aortic valve insufficiency, aortic insufficiency, AI, aortic regurgitation, AR, aortic valve incompetence, aortic valve prolapse, aortic valve insufficiency, abnormalities in the aortic valve leaflets, diagnosis, treatment
