Aortic regurgitation

Aortic regurgitation

Anesthetic relevance
Anesthetic management	{{{anesthetic_management}}}
Specialty
Signs and symptoms
Diagnosis
Treatment
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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
• 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.

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

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