Difference between revisions of "Aortic regurgitation"
From WikiAnesthesia
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Aortic regurgitation (AR) or insufficiency (AI) may be acute or chronic, and anesthetic goals may change as a result. These lesions are often a result of connective tissue disease or bicuspid AV, which predisposes patients to developing aortic aneurysms and dissection leading to aortic root dilation that disrupts the normal AV architecture, causing the valve cusps and leaflets to separate, resulting in AR. | |||
== Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. --> == | == Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. --> == | ||
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* Increased risk of perioperative cardiovascular decompensation<ref>{{Citation|title=Copyright|date=2008|url=http://dx.doi.org/10.1016/b978-1-4160-3998-3.50002-5|work=Stoelting's Anesthesia and Co-Existing Disease|pages=iv|publisher=Elsevier|access-date=2021-12-03}}</ref> | * Increased risk of perioperative cardiovascular decompensation<ref>{{Citation|title=Copyright|date=2008|url=http://dx.doi.org/10.1016/b978-1-4160-3998-3.50002-5|work=Stoelting's Anesthesia and Co-Existing Disease|pages=iv|publisher=Elsevier|access-date=2021-12-03}}</ref> | ||
* Patient may have underlying connective tissue disease (Marfan, Ehlers-Danlos), bicuspid aortic valve, or inflammatory diseases of the aorta. | |||
=== Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. --> === | === Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. --> === | ||
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* Hemodynamic goals are to maintain forward flow and decrease regurgitant volume | * Hemodynamic goals are to maintain forward flow and decrease regurgitant volume | ||
** Preload: normal-high to augment CO | ** Preload: normal-high to augment CO | ||
** Afterload: low-normal to promote forward flow | ** Afterload: low-normal to promote forward flow, reducing aortic diastolic pressure0 | ||
** Rate: high-normal | ** Rate: high-normal (80s) to reduce time in diastole for regurgitation to occur | ||
** Rhythm: sinus (rate more important) | ** Rhythm: sinus (rate more important) | ||
** Contractility: high-normal | ** Contractility: high-normal | ||
* Hypotension should not be treated with pure vasoconstrictors, as arterial vasoconstriction will increase afterload and increase the regurgitant fraction. | |||
* Avoid medications such as phenylephrine which cause increased afterload and reflex bradycardia both of which contribute to increased AR. | |||
* Hypotension should be treated with augmentation of heart rate, preload and contractility. | |||
=== Postoperative management<!-- Describe how this comorbidity may influence postoperative management. --> === | === Postoperative management<!-- Describe how this comorbidity may influence postoperative management. --> === | ||
== Related surgical procedures<!-- List and briefly describe any procedures which may be performed specifically to treat this comorbidity or its sequelae. If none, this section may be removed. --> == | == Related surgical procedures<!-- List and briefly describe any procedures which may be performed specifically to treat this comorbidity or its sequelae. If none, this section may be removed. --> == | ||
[[Aortic valve repair or replacement]] | |||
== Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. --> == | == Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. --> == | ||
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== Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> == | == Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> == | ||
* Dyspnea on exertion | |||
* orthopnea | |||
* PND | |||
* Palpitations | |||
* Angina | |||
* Cyanosis in acute cases | |||
== Diagnosis<!-- Describe how this comorbidity is diagnosed. --> == | == Diagnosis<!-- Describe how this comorbidity is diagnosed. --> == | ||
Revision as of 03:42, 5 December 2021
Aortic regurgitation
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| Anesthetic management |
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Aortic regurgitation (AR) or insufficiency (AI) may be acute or chronic, and anesthetic goals may change as a result. These lesions are often a result of connective tissue disease or bicuspid AV, which predisposes patients to developing aortic aneurysms and dissection leading to aortic root dilation that disrupts the normal AV architecture, causing the valve cusps and leaflets to separate, resulting in AR.
Anesthetic implications
Preoperative optimization
- Increased risk of perioperative cardiovascular decompensation[1]
- Patient may have underlying connective tissue disease (Marfan, Ehlers-Danlos), bicuspid aortic valve, or inflammatory diseases of the aorta.
Intraoperative management
- Hemodynamic goals are to maintain forward flow and decrease regurgitant volume
- Preload: normal-high to augment CO
- Afterload: low-normal to promote forward flow, reducing aortic diastolic pressure0
- Rate: high-normal (80s) to reduce time in diastole for regurgitation to occur
- Rhythm: sinus (rate more important)
- Contractility: high-normal
- Hypotension should not be treated with pure vasoconstrictors, as arterial vasoconstriction will increase afterload and increase the regurgitant fraction.
- Avoid medications such as phenylephrine which cause increased afterload and reflex bradycardia both of which contribute to increased AR.
- Hypotension should be treated with augmentation of heart rate, preload and contractility.
Postoperative management
Related surgical procedures
Aortic valve repair or replacement
Pathophysiology
- Hemodynamic sequelae of AI:
- LA distension > Volume overload > Subendothelial ischemia
- CHF > pulmonary edema
- RV failure > pulmonary HTN
- In acute AI, sudden increase in LV volume can induce cardiogenic shock and pulmonary edema
- Sudden AI that does not allow time for compensatory LV dilation can result in acute pulmonary congestion
Signs and symptoms
- Dyspnea on exertion
- orthopnea
- PND
- Palpitations
- Angina
- Cyanosis in acute cases
Diagnosis
Treatment
Medication
- Diuretics, anticoagulants
- Immediate management of acute AI involves afterload reduction (nitroprusside) & augmentation of contractility & rate (dobutamine)
Surgery
- Severe acute AI may require emergency AV repair/replacement
- Note that intra-aortic balloon pump is contraindicated
Prognosis
Epidemiology
References
- ↑ "Copyright", Stoelting's Anesthesia and Co-Existing Disease, Elsevier, pp. iv, 2008, retrieved 2021-12-03
Top contributors: Olivia Sutton and Chris Rishel