Aortic Insufficiency/regurgitation

Aortic insufficiency, also known as aortic regurgitation, is a heart valve disorder that occurs when the aortic valve does not close properly during diastole, causing the blood to leak back into the left ventricle. This can lead to an increase in the volume of blood in the left ventricle, leading to increased workload on the heart and eventually resulting in heart failure. In this essay, we will discuss the case, pathophysiology, signs and symptoms, investigations, treatment, and advice for aortic insufficiency.

Case:
Mr. X, a 60-year-old male, presented with shortness of breath on exertion, chest pain, and fatigue. He had a history of hypertension, diabetes, and hyperlipidemia. Upon examination, a diastolic murmur was heard over the aortic valve. An echocardiogram was performed, which showed aortic insufficiency with an ejection fraction of 55%.

Pathophysiology

The aortic valve normally opens during systole to allow blood to flow from the left ventricle into the aorta, and closes during diastole to prevent backflow of blood into the ventricle. In aortic insufficiency, the aortic valve does not close properly during diastole, allowing some of the blood to flow back into the left ventricle. This results in an increase in volume in the left ventricle, leading to an increase in workload and eventually resulting in left ventricular hypertrophy and heart failure.

Signs and Symptoms:

The signs and symptoms of aortic insufficiency can be acute or chronic. Acute aortic insufficiency can present with sudden onset of severe dyspnea, chest pain, and hypotension. Chronic aortic insufficiency may present with fatigue, dyspnea on exertion, chest pain, palpitations, and eventually symptoms of heart failure. A diastolic murmur heard over the aortic valve is a classic finding.

Investigations:

Echocardiography is the primary diagnostic tool for aortic insufficiency. It can assess the severity of the regurgitation, the size of the left ventricle, and the ejection fraction. Other investigations may include electrocardiography (ECG), chest X-ray, and cardiac MRI.

Treatment:

The treatment of aortic insufficiency depends on the severity of the condition. Mild aortic insufficiency may not require treatment, but close monitoring is necessary. In cases of moderate to severe aortic insufficiency, medical therapy may be required to control blood pressure and heart rate. Surgical intervention may be necessary in severe cases, such as aortic valve replacement or repair.

Dos and Don’ts:

Patients with aortic insufficiency should avoid strenuous physical activity and should be encouraged to maintain a healthy weight and blood pressure. They should also be advised to quit smoking and avoid alcohol. Patients should seek medical attention if they experience any chest pain or shortness of breath.

References:

• Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(25):e1159-e1195.
• Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). J Am Coll Cardiol. 2008;52:e1-e142.
• Enriquez-Sarano M, Akins CW, Vahanian A. Mitral regurgitation. Lancet. 2009;373(9672):1382-1394.
• Adams DH, Anyanwu AC, Rahimtoola SH. The scope of valve repair for acquired mitral valve disease. Circulation. 2008;118(19):1873-1881.
• O’Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e362-e425.