*3.13.1 Epidemiology and aetiology*

The reasons of aortic regurgitation (AR) are many and can be credited to a disruption of any components of the functional unit of the aortic root valve composite (e.g., cusps, sinuses of Valsalva, sinotubular junction, annulus). In general, the causes can be divided into those that involve the valve cusps (e.g., calcific degeneration, congenitally bicuspid valve, infective endocarditis, rheumatic disease, myxomatous degeneration) and those that encompass the aortic root (e.g., aortic dissection, aortitis of various etiologies such as syphilis, connective tissue disorders such as Marfan syndrome) [43].

### *3.13.2 Pathophysiology*

The pathophysiology of AR is determined by the speed of onset and duration of the disease process. In acute AR, typically caused by aortic dissection, infective endocarditis, trauma, or valve prosthesis failure, there is an abrupt escalation in left ventricular end-diastolic volume because of the regurgitation. Since the left ventricle has restricted compliance and does not have enough time to gradually adapt to the extra volume, the left ventricular end-diastolic pressure (LVEDP) rises rapidly [44, 45].

In chronic AR, there is a gradual and stealthy evolution of left ventricular (LV) dilation and eccentric hypertrophy because of an increase in left ventricular end-diastolic volume, LVEDP, and wall stress. Dilation of the LV maintains normal systolic function and forward flow but requiring extra work to achieve normality. Sooner or later, the hypertrophic response is exhausted, and LVEF deteriorates as afterload increases, resulting in heart failure and its related clinical presentation [44].

### *3.13.3 Clinical features*

Patients with acute AR present with unexpected or precipitously cardiovascular collapse, which is a life-threatening emergency. They often demonstrate ischemic symptoms because of the diminished coronary blood flow and heightened myocardial oxygen demand. In comparison, patients with chronic AR are often asymptomatic for an extended time because of the compensator remodelling of their LV mentioned earlier. Once the compensatory response is depleted, the patients

experience heart failure symptoms such as exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Patients may also suffer palpitations and angina [46].

The classic murmur of AR is an early diastolic, blowing, a decrescendo murmur heard best at the level of the diaphragm at the left sternal border while the patient is sitting, leaning forward, and in deep exhalation.

Classic signs of widened pulse pressure may also be found, including Corrigan or water-hammer pulse, De Musset sign (bobbing of the head with heartbeats), Quincke pulse (pulsations of the lip and fingers), Traube sign (pistol shot sounds over the femoral artery), and Müller sign (pulsations of the uvula).

### *3.13.4 Diagnostic criteria*

Transthoracic echocardiography with Doppler colour-flow is the most useful tool for the diagnosis of AR. The jet width and vena contracta width on Doppler colour-flow are used to qualitatively assess the severity of AR, whereas the regurgitant volume, regurgitant fraction, and regurgitant orifice area are used for the quantitative assessment.

### *3.13.5 Management of aortic valve disease*

### *3.13.5.1 Medical management*

Many adverse outcomes in adults with valvular heart disease are due to sequelae of the disease process, including atrial fibrillation, embolic events, left ventricular (LV) dysfunction, pulmonary hypertension, and endocarditis. Patients with valvular heart disease are best cared for in the context of a multidisciplinary heart valve clinic [47].

Medical therapy in adults with valvular heart disease focuses on prevention and treatment of complications because there are no specific therapies to prevent progression of the valve disease itself apart from primary and secondary prophylaxis of rheumatic fever. Rheumatic fever is a multiorgan inflammatory disease that occurs 10 days to 3 weeks after group A streptococcal pharyngitis. The clinical diagnosis is based on the conjunction of an antecedent streptococcal throat infection and classic manifestations of the disease, including carditis, polyarthritis, chorea, erythema marginatum, and subcutaneous nodules [48]. Reducing the frequency of streptococcal pharyngitis with benzylpenicillin monthly intramuscular injection helps to reduce the progression of Rheumatic heart disease. The risk of recurrent disease is related to the number of previous episodes, time interval since the last episode, the risk of exposure to streptococcal infections (contact with children or crowded situations), and patient age. A longer duration of secondary prevention is recommended in patients with evidence of carditis or persistent valvular disease than in those with no evidence of valvular damage [49].

Endocarditis prophylaxis guidelines recommend antibiotics therapy before dental procedures, or other procedures associated with bacteraemia, in adults with prosthetic valves but not in patients with native valve disease unless the patient had an episode of endocarditis, dental hygiene and gum health are the primary preventive measure to reduce endocarditis [50].

Prevention of embolic events in patients with valvular heart disease, particularly those with prosthetic valves, MS, or AF, is a key component of optimal medical therapy.

Therapy for the prevention of embolic events in patients with valvular heart disease typically includes antiplatelet agents or long-term warfarin anticoagulation [51, 52]. There is data on the use of newer anticoagulants, such as direct thrombin

**27**

*Aortic Valve Disease: State of the Art*

*DOI: http://dx.doi.org/10.5772/intechopen.93311*

presentations, and computer-based material).

outcomes with concurrent coronary revascularisation.

hypertension or AF.

rate and rhythm.

tive period [54].

*3.13.5.2 Patient education*

inhibitors and anti-Xa agents, for prevention of embolic events in patients with valve disease [53]. At the initiation of therapy, a target INR and acceptable range are defined by the referring physician for each patient on the basis of published guidelines and clinical factors unique to that patient, In addition, patient education about anticoagulation, possible dietary and drug interactions, recognition of complications of therapy, and the need for careful monitoring of the INR is provided verbally and through the use of a variety of media (such as pamphlets, recorded

Periodic evaluation of disease severity by echocardiography and clinical evaluation of the LV response to chronic volume and/or pressure overload allows optimal timing of surgical and percutaneous interventions. General health maintenance is important, including evaluation and treatment of coronary disease risk factors, regular exercise, standard immunisations. Both pneumococcal and annual influenza vaccinations are recommended for all adults older than 65 years and are especially important in patients with valvular disease, in whom the increased hemodynamic demands of acute infection may lead to cardiac decompensation. In younger patients with valve disease, routine immunisation is only indicated in conditions associated with immunocompromise are also present and optimal dental care. Management of concurrent cardiovascular disease follows standard approaches with modification, as needed, based on the potential confounding effects of valve haemodynamics. Evaluation of coronary anatomy usually is needed before valve surgery because of the high prevalence of coronary disease and improved surgical

Periodic noninvasive monitoring is essential for the optimal timing of interventions in patients with valve dysfunction. Disease progression may be evident as changes in valve anatomy or motion; an increase in the severity of valve stenosis or regurgitation; LV dilation, hypertrophy, or dysfunction in response to pressure and/ or volume overload; or secondary effects of the valvular lesion, such as pulmonary

Although the goal in the management of patients with valvular disease is to avoid symptoms and the need for medical therapy by optimising the timing of surgical intervention, some patients have persistent symptoms after surgery, have symptoms only in response to superimposed hemodynamic stress (such as pregnancy), or are not candidates for surgical intervention. In these situations, medical therapy is based primarily on adjustment of loading conditions and control of heart

Most adverse outcomes of noncardiac surgery in adults with valve disease are due to failure to recognise the presence of valve disease preoperatively. When valve disease is suspected from history or physical examination findings, echocardiography is appropriate to identify and define the severity of any valve lesions. In patients with valvular disease undergoing noncardiac surgery, management focuses on an accurate assessment of disease severity and symptom status, with appropriate hemodynamic monitoring and optimisation of loading conditions in the periopera-

Patient education is the key to compliance with periodic noninvasive monitoring, prevention of complications, and the early recognition of symptoms in patients with valvular heart disease. Each patient should understand the expected long-term prognosis, potential complications, typical symptoms, the rationale for sequential monitoring, and the indications for surgical intervention. Appropriate education avoids needless concern and prompts early reporting of symptoms, allowing

### *Aortic Valve Disease: State of the Art DOI: http://dx.doi.org/10.5772/intechopen.93311*

*Advances in Complex Valvular Disease*

*3.13.4 Diagnostic criteria*

quantitative assessment.

*3.13.5.1 Medical management*

valve clinic [47].

*3.13.5 Management of aortic valve disease*

no evidence of valvular damage [49].

tive measure to reduce endocarditis [50].

sitting, leaning forward, and in deep exhalation.

experience heart failure symptoms such as exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. Patients may also suffer palpitations and angina [46]. The classic murmur of AR is an early diastolic, blowing, a decrescendo murmur heard best at the level of the diaphragm at the left sternal border while the patient is

Classic signs of widened pulse pressure may also be found, including Corrigan or water-hammer pulse, De Musset sign (bobbing of the head with heartbeats), Quincke pulse (pulsations of the lip and fingers), Traube sign (pistol shot sounds

Transthoracic echocardiography with Doppler colour-flow is the most useful tool for the diagnosis of AR. The jet width and vena contracta width on Doppler colour-flow are used to qualitatively assess the severity of AR, whereas the regurgitant volume, regurgitant fraction, and regurgitant orifice area are used for the

Many adverse outcomes in adults with valvular heart disease are due to sequelae of the disease process, including atrial fibrillation, embolic events, left ventricular (LV) dysfunction, pulmonary hypertension, and endocarditis. Patients with valvular heart disease are best cared for in the context of a multidisciplinary heart

Medical therapy in adults with valvular heart disease focuses on prevention and treatment of complications because there are no specific therapies to prevent progression of the valve disease itself apart from primary and secondary prophylaxis of rheumatic fever. Rheumatic fever is a multiorgan inflammatory disease that occurs 10 days to 3 weeks after group A streptococcal pharyngitis. The clinical diagnosis is based on the conjunction of an antecedent streptococcal throat infection and classic manifestations of the disease, including carditis, polyarthritis, chorea, erythema marginatum, and subcutaneous nodules [48]. Reducing the frequency of streptococcal pharyngitis with benzylpenicillin monthly intramuscular injection helps to reduce the progression of Rheumatic heart disease. The risk of recurrent disease is related to the number of previous episodes, time interval since the last episode, the risk of exposure to streptococcal infections (contact with children or crowded situations), and patient age. A longer duration of secondary prevention is recommended in patients with evidence of carditis or persistent valvular disease than in those with

Endocarditis prophylaxis guidelines recommend antibiotics therapy before dental procedures, or other procedures associated with bacteraemia, in adults with prosthetic valves but not in patients with native valve disease unless the patient had an episode of endocarditis, dental hygiene and gum health are the primary preven-

those with prosthetic valves, MS, or AF, is a key component of optimal medical

Therapy for the prevention of embolic events in patients with valvular heart disease typically includes antiplatelet agents or long-term warfarin anticoagulation [51, 52]. There is data on the use of newer anticoagulants, such as direct thrombin

Prevention of embolic events in patients with valvular heart disease, particularly

over the femoral artery), and Müller sign (pulsations of the uvula).

**26**

therapy.

inhibitors and anti-Xa agents, for prevention of embolic events in patients with valve disease [53]. At the initiation of therapy, a target INR and acceptable range are defined by the referring physician for each patient on the basis of published guidelines and clinical factors unique to that patient, In addition, patient education about anticoagulation, possible dietary and drug interactions, recognition of complications of therapy, and the need for careful monitoring of the INR is provided verbally and through the use of a variety of media (such as pamphlets, recorded presentations, and computer-based material).

Periodic evaluation of disease severity by echocardiography and clinical evaluation of the LV response to chronic volume and/or pressure overload allows optimal timing of surgical and percutaneous interventions. General health maintenance is important, including evaluation and treatment of coronary disease risk factors, regular exercise, standard immunisations. Both pneumococcal and annual influenza vaccinations are recommended for all adults older than 65 years and are especially important in patients with valvular disease, in whom the increased hemodynamic demands of acute infection may lead to cardiac decompensation. In younger patients with valve disease, routine immunisation is only indicated in conditions associated with immunocompromise are also present and optimal dental care. Management of concurrent cardiovascular disease follows standard approaches with modification, as needed, based on the potential confounding effects of valve haemodynamics. Evaluation of coronary anatomy usually is needed before valve surgery because of the high prevalence of coronary disease and improved surgical outcomes with concurrent coronary revascularisation.

Periodic noninvasive monitoring is essential for the optimal timing of interventions in patients with valve dysfunction. Disease progression may be evident as changes in valve anatomy or motion; an increase in the severity of valve stenosis or regurgitation; LV dilation, hypertrophy, or dysfunction in response to pressure and/ or volume overload; or secondary effects of the valvular lesion, such as pulmonary hypertension or AF.

Although the goal in the management of patients with valvular disease is to avoid symptoms and the need for medical therapy by optimising the timing of surgical intervention, some patients have persistent symptoms after surgery, have symptoms only in response to superimposed hemodynamic stress (such as pregnancy), or are not candidates for surgical intervention. In these situations, medical therapy is based primarily on adjustment of loading conditions and control of heart rate and rhythm.

Most adverse outcomes of noncardiac surgery in adults with valve disease are due to failure to recognise the presence of valve disease preoperatively. When valve disease is suspected from history or physical examination findings, echocardiography is appropriate to identify and define the severity of any valve lesions. In patients with valvular disease undergoing noncardiac surgery, management focuses on an accurate assessment of disease severity and symptom status, with appropriate hemodynamic monitoring and optimisation of loading conditions in the perioperative period [54].
