Aortic Regurgitation 

 

 

Considerations

 

  • ↑ risk of perioperative cardiovascular decompensation

  • Hemodynamic sequelae of aortic regurgitation: 

    • Left atrial (LA) distension/volume overload & subendothelial ischemia

    • LA dilation & eccentric hypertrophy, potential for ischemia & arrhythmias

    • CHF & pulmonary edema

    • RVF & pulmonary HTN

    • Acute aortic regurgitation:

      • Sudden increase in LV volume, cardiogenic shock & pulmonary edema

      • ↑ sympathetic drive

  • Comorbid disease:

    • Aortic arch dilation (Marfan’s, dissection, infection, ankylosing spondilitis)

    • Valvulopathy (aortic stenosis, infective endocarditis, SLE)

    • Ischemic heart disease 

  • Management of medical therapy (diuretics, anticoagulants)

 

 

Hemodynamic goals

 

  • Key is to maintain forward flow & ↓ regurgitant volume

  • Preload: normal to high to augment cardiac output

  • Rate: high normal

  • Rhythm: sinus if possible, but rate is more important

  • Contractility: maintain or augment 

  • Afterload: keep afterload low to promote forward flow 

Management of severe acute aortic regurgitation

  • Sudden aortic incompetence does not allow time for compensatory LV dilation & results in acute pulmonary congestion

  • Immediate management involves afterload reduction (nitroprusside) & augmentation of contractility & rate (dobutamine)

  • Likely needs emergency aortic valve replacement/repair 

  • Intra-aortic balloon pump is CONTRAINDICATED

 

Further Reading  

  • Stoelting's Anesthesia and Co-Existing Disease, 7th Edition, Chapter 6