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Education in Heart
Acute native aortic regurgitation: clinical presentation, diagnosis and management
  1. Jay Voit1,
  2. Catherine M Otto1,
  3. Christopher R Burke2
  1. 1 Division of Cardiology, University of Washington, Seattle, Washington, USA
  2. 2 Department of Cardiac Surgery, University of Washington, Seattle, Washington, USA
  1. Correspondence to Dr Christopher R Burke, Cardiac Surgery, University of Washington, Box 356310, Washington, USA; cburke22{at}uw.edu

https://doi.org/10.1136/heartjnl-2021-320157

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    Learning objectives

    • To improve knowledge of the aetiology and clinical presentation of acute aortic regurgitation.

    • To discuss the diagnostic approach with suspected acute aortic regurgitation using complementary imaging techniques.

    • To understand basic principles in the management of acute aortic regurgitation including surgery.

    Introduction

    Acute native valve aortic regurgitation (AR) is a rapidly fatal condition resulting from the sudden loss of valve competency. Acute AR requires prompt intervention yet often is missed because the clinical presentation is not recognised. The large volume of retrograde diastolic flow into a left ventricle (LV) without compensatory dilation results in an abrupt decrease in cardiac output and increase in LV end-diastolic pressure (figure 1). Urgent surgical intervention to restore valve competency and treat the underlying cause is essential. Options for medical stabilisation or palliative care are limited. This review covers the aetiology, haemodynamics, clinical presentation, diagnosis, medical stabilisation and surgical management of patients with acute native valve AR.

    Figure 1

    Acute AR. Summary of the pathophysiology, clinical presentation, approach to diagnosis and treatment approach for patients with acute aortic valve regurgitation. AR, aortic regurgitation; AVR, aortic valve replacement; BP, blood pressure; CW, continuous wave Doppler ultrasound; CXR, chest X-ray; EDP, end-diastolic pressure; IABP, intra-aortic balloon pump; LV, left ventricle; LVAD, LV assist device; MR, mitral regurgitation; STJ, sinotubular junction of the aorta.

    Aetiology

    The aortic valve is a complex, three-dimensional (3D) structure that prevents retrograde blood flow from the aorta into the LV during diastole. The valve structure includes the three semilunar leaflets with support provided by the aortic sinuses and sinotubular junction.1 Each valve leaflet is attached in semicircular fashion to its associated sinus with central attachment of each leaflet just below the anatomic aortoventricular junction and commissural attachment at the sinotubular junction. Acute AR can arise from disruption of the valve leaflets themselves (primary AR) or of the …

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    Footnotes

    • Twitter @chrisryanburke

    • Contributors All authors contributed to manuscript inception, drafting, and final revisions.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Commissioned; externally peer reviewed.

    • Author note References which include a * are considered to be key references.