Aortic Regurgitation
Considerations
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↑ risk of perioperative cardiovascular decompensation
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Hemodynamic sequelae of aortic regurgitation:
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Left atrial (LA) distension/volume overload & subendothelial ischemia
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LA dilation & eccentric hypertrophy, potential for ischemia & arrhythmias
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CHF & pulmonary edema
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RVF & pulmonary HTN
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Acute aortic regurgitation:
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Sudden increase in LV volume, cardiogenic shock & pulmonary edema
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↑ sympathetic drive
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Comorbid disease:
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Aortic arch dilation (Marfan’s, dissection, infection, ankylosing spondilitis)
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Valvulopathy (aortic stenosis, infective endocarditis, SLE)
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Ischemic heart disease
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Management of medical therapy (diuretics, anticoagulants)
Hemodynamic goals
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Key is to maintain forward flow & ↓ regurgitant volume
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Preload: normal to high to augment cardiac output
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Rate: high normal
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Rhythm: sinus if possible, but rate is more important
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Contractility: maintain or augment
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Afterload: keep afterload low to promote forward flow
Management of severe acute aortic regurgitation
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Sudden aortic incompetence does not allow time for compensatory LV dilation & results in acute pulmonary congestion
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Immediate management involves afterload reduction (nitroprusside) & augmentation of contractility & rate (dobutamine)
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Likely needs emergency aortic valve replacement/repair
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Intra-aortic balloon pump is CONTRAINDICATED
Further Reading
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Stoelting's Anesthesia and Co-Existing Disease, 7th Edition, Chapter 6