Aortic regurgitation: epidemiologic, etiologic, and pathophysiologic characteristics

The presented review concerns aortic regurgitation which occupies a significant place in the structure of valvular heart disease. The detailed anatomic and physiologic description of the aortic valve is provided. The characteristics of sinotubular, ventricular-aortic junctions, and virtual aortic annulus are presented. There are data about prevalence of aortic regurgitation on the basis of results of population studies, indicating the increase in incidence of aortic regurgitation among individuals older 70–74 years. The detailed etiologic structure of this valvular pathology is described with specifying of the most common causes of both aortic disease and aortic cusps alterations. In particular, there are some aortic diseases, resulting in acute aortic regurgitation, including acute aortic dissection and paravalvular regurgitation in incompetence of the prosthetic aortic valve; in chronic one – idiopathic dilation of the aortic root, inherited connective tissue dysplasias (Ehlers–Danlos, Marfan, and Loeys–Dietz syndromes), bicuspid aortic valve, aortitis of various origin, seronegative arthropathies (reactive, psoriatic arthritis, ankylosing spondylitis) etc. Infective endocarditis and traumatic exposure are commonly responsible for development of acute regurgitation due to aortic cusps abnormalities. Chronic aortic regurgitation as a consequence valve defects occurs in rheumatic heart disease, degenerative changes, congenital anomalies, systemic connective tissue diseases (systemic lupus erythematosus, rheumatoid arthritis), non-specific aortoarteritis, etc. The special attention is paid to pathophysiologic features of acute and chronic aortic regurgitation in the review. Acute aortic regurgitation is characterized by sudden increase in end-diastolic volume and due to the noncompliant left ventricle of normal size, it undergoes abrupt exposure a significant pre-load and after-load which results in decrease of left ventricle systolic function and stroke volume despite on relative preservation of contractile function of myocardium. In contrast to acute aortic regurgitation it is remarkable in its chronic form slow, progressive influence by increased overload of the left ventricle with possibility to adapt driven by its gradual dilation and hypertrophy.

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Left ventricle reverse remodeling in chronic aortic regurgitation patients with dilated ventricle after aortic valve replacement

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-022-01754-5 ◽

2022 ◽

Vol 17 (1) ◽

Author(s):

Ming-Kui Zhang ◽

Li-Na Li ◽

Hui Xue ◽

Xiu-Jie Tang ◽

He Sun ◽

...

Keyword(s):

Aortic Valve ◽

Left Ventricle ◽

Aortic Valve Replacement ◽

Aortic Regurgitation ◽

Left Ventricular ◽

Reverse Remodeling ◽

Left Ventricle Remodeling ◽

Lv Remodeling ◽

Chronic Aortic Regurgitation

Abstract Background Aortic valve replacement (AVR) for chronic aortic regurgitation (AR) with a severe dilated left ventricle and dysfunction leads to left ventricle remodeling. But there are rarely reports on the left ventricle reverse remodeling (LVRR) after AVR. This study aimed to investigate the LVRR and outcomes in chronic AR patients with severe dilated left ventricle and dysfunction after AVR. Methods We retrospectively analyzed the clinical datum of chronic aortic regurgitation patients who underwent isolated AVR. The LVRR was defined as an increase in left ventricular ejection fraction (LVEF) at least 10 points or a follow-up LVEF ≥ 50%, and a decrease in the indexed left ventricular end-diastolic diameter of at least 10%, or an indexed left ventricular end-diastolic diameter ≤ 33 mm/m2. The changes in echocardiographic parameters after AVR, survival analysis, the predictors of major adverse cardiac events (MACE), the association between LVRR and MACE were analyzed. Results Sixty-nine patients with severe dilated left ventricle and dysfunction underwent isolated AVR. LV remodeling in 54 patients and no LV remodeling in 15 patients at 6–12 months follow-up. The preoperative left ventricular dimensions and volumes were larger, and the EF was lower in the LV no remodeling group than those in the LV remodeling group (all p < 0.05). The adverse LVRR was the predictor for MACE at follow-up. The mean follow-up period was 47.29 months (range 6 to 173 months). The rate of freedom from MACE was 94.44% at 5 years and 92.59% at 10 years in the remodeling group, 60% at 5 years, and 46.67% at 10 years in the no remodeling group. Conclusions The left ventricle remodeling after AVR was the important predictor for MACE. LV no remodeling may not be associated with benefits from AVR for chronic aortic regurgitation patients with severe dilated LV and dysfunction.

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Prognostic Markers and Long‐Term Outcomes After Aortic Valve Replacement in Patients With Chronic Aortic Regurgitation

Journal of the American Heart Association ◽

10.1161/jaha.120.018292 ◽

2020 ◽

Vol 9 (24) ◽

Author(s):

Min‐Seok Kim ◽

Jung Hwan Kim ◽

Hyun‐Chel Joo ◽

Sak Lee ◽

Young‐Nam Youn ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Flow Velocity ◽

Aortic Regurgitation ◽

Valve Replacement ◽

Systolic Function ◽

Velocity Ratio ◽

Transmitral Flow ◽

Chronic Aortic Regurgitation

Background The objectives of the present study were (1) to evaluate the echocardiographic prognostic factors associated with improved left ventricular (LV) systolic function after aortic valve replacement, and (2) to compare the long‐term outcomes after aortic valve replacement in chronic aortic regurgitation (AR) patients with or without LV dysfunction. Methods and Results A total of 280 patients who underwent aortic valve replacement because of chronic aortic regurgitation were studied. Patients with reduced LV systolic function (LV ejection fraction [LVEF] <50%; group reduced LVEF [rEF]; N=80) were compared with those with preserved LV systolic function (LVEF ≥50%; group preserved LVEF; N=200). Postoperative clinical outcomes, overall survival, and freedom from cardiac death were compared. Postoperative echocardiographic examinations were reviewed, and changes in echocardiographic parameters were analyzed. The parameters related to LVEF improvement or normalization were evaluated, and risk factors affecting long‐term survival were identified. Follow‐up was complete in 100% of patients, with a median follow‐up of 104.8 months. Overall and cardiac mortality‐free survival rates at postoperative 10 years were 80.1% and 92.9% and 87.3% and 97.2% in groups rEF and preserved LVEF, respectively ( P =0.036 and P =0.058, respectively). LVEF tended to decrease in the early postoperative period but improved thereafter in both groups. Preoperative early diastolic transmitral flow velocity/mitral annular tissue velocity ratio was a parameter of postoperative improvement or normalization of LVEF in all patients (area under the curve, 0.719; P =0.003) and in group rEF patients (area under the curve, 0.726; P =0.011) with a cutoff value of 12.73. Preoperative early diastolic transmitral flow velocity/mitral annular tissue velocity ratio also was the parameter of overall survival in all patients (hazard ratio [HR], 1.08; P =0.001) and in group rEF patients (HR, 1.08; P =0.005). Conclusions Long‐term outcomes and survival after aortic valve replacement were related to preoperative LV function in patients with chronic aortic regurgitation. Preoperative early diastolic transmitral flow velocity/mitral annular tissue velocity ratio was correlated with the postoperative improvement or normalization of LVEF and long‐term survival, especially in group rEF patients.

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Faculty Opinions recommendation of Improved outcomes after aortic valve surgery for chronic aortic regurgitation with severe left ventricular dysfunction.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.1087597.540609 ◽

2007 ◽

Author(s):

John A Paraskos

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Left Ventricular Dysfunction ◽

Ventricular Dysfunction ◽

Left Ventricular ◽

Valve Surgery ◽

Aortic Valve Surgery ◽

Severe Left Ventricular Dysfunction ◽

Improved Outcomes ◽

Chronic Aortic Regurgitation

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Presence of adipose tissue in aortic valves from aortic regurgitation patients: pathophysiological role and clinical implications

European Heart Journal ◽

10.1093/ehjci/ehaa946.3721 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Sadaba Cipriain ◽

A.M Navarro Echeverria ◽

C.R Tiraplegui Garjon ◽

A Garcia De La Pena Urtasun ◽

V Arrieta Paniagua ◽

...

Keyword(s):

Adipose Tissue ◽

Aortic Valve ◽

Aortic Regurgitation ◽

Systolic Function ◽

Statistical Significance ◽

Left Ventricular Systolic Function ◽

Left Ventricular ◽

Funding Source ◽

Matrix Remodeling ◽

Aortic Valves

Abstract Introduction Adipose tissue is a common constituent of the heart and it is located, without great clinical relevance, frequently in the pericardium. The presence of adipose tissue in the aortic valve is rare, with unknown significance on valve structural properties and function. Aortic regurgitation (AR) is the third most prevalent valve disease, although it is uncommon to find it in isolation. Myxoid degeneration may be the cause or result of AR, although the pathophysiology remains poorly understood. Purpose To describe and characterize the presence of adipose tissue in the aortic valves from a cohort of AR patients. Methods 116 patients undergoing aortic valve replacement due to severe AR were enrolled. We classified them in two groups according to the histological results showing presence or absence of adipose tissue in the aortic valves. In the valve tissue molecular analysis were performed by RT-PCR, Western Blot and ELISA to analyze markers of adipocytes (leptin, adiponectin, resistin), inflammation (Rantes, interleukin-6, interleukin-1β), extracellular matrix remodeling (metalloproteinases-1, -2 and -9), proteoglycans (aggrecan, hyaluronan, lumican, syndecan-1, decorin) and fibrosis (collagens, fibronectin). Results Adipose tissue was found in 63% of the aortic valves analyzed. Baseline characteristics (age, hypertension, dyslipidemia, diabetes, smoking, left ventricular telediastolic diameter, left ventricular systolic function, ascending aorta) were similar in patients presenting valve adipose tissue as compared with patients without valve adipose tissue. Valves containing adipocytes exhibited a higher leptin content (p<0.001), fibronectin (p<0.01), decorin (p<0,0001), hyaluronan (p=0.03), aggrecan (p=0.04) and metalloproteinase 1 (p=0.03). Interestingly, the presence of adipocytes in the valve was positively correlated with valve thickness measured by echocardiogram (Pearson chi2 statistical significance = 26.3345 p<0.001). Conclusion To our knowledge, this is the first study that describes the presence of adipose cells in aortic valves from a cohort of AR patients. Aortic valves containing adipocytes were thicker and exhibited significant higher levels of proteoglycans, suggesting that adipocytes could contribute to the myxomatous degeneration process. Our results propose that the valve adipose tissue could play a role in the pathophysiology of AR. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Gobierno de Navarra

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Echocardiographic Predictors of Left Ventricular Dysfunction after Aortic Valve Surgery in Children with Chronic Aortic Regurgitation

Congenital Heart Disease ◽

10.1111/chd.12009 ◽

2012 ◽

Vol 8 (4) ◽

pp. 308-315 ◽

Cited By ~ 8

Author(s):

Elif Seda Selamet Tierney ◽

Dana Gal ◽

Kimberly Gauvreau ◽

Jing Zhou ◽

Yelda Soluk ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Left Ventricular Dysfunction ◽

Ventricular Dysfunction ◽

Left Ventricular ◽

Valve Surgery ◽

Aortic Valve Surgery ◽

Chronic Aortic Regurgitation

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Reexamining remodelling in children

European Journal of Cardio-Thoracic Surgery ◽

10.1093/ejcts/ezz380 ◽

2020 ◽

Vol 57 (6) ◽

pp. 1091-1097

Author(s):

Shunsuke Matsushima ◽

Alexander Heß ◽

Julia Renata Lämmerzahl ◽

Irem Karliova ◽

Christian Giebels ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Regurgitation ◽

Connective Tissue Diseases ◽

Graft Size ◽

Effective Height ◽

Annular Dilatation ◽

Increased Risk ◽

Median Diameter ◽

The Mean

Abstract OBJECTIVES Some studies have suggested that root remodelling is unsuitable as valve-sparing aortic root replacement in children because of the increased risk of valve failure. This study reviewed our experience with root remodelling in children. METHODS All patients who underwent root remodelling at the age of ≤18 years between 1999 and 2016 were evaluated. In 2004, cusp effective height was measured intraoperatively and prolapse was corrected with central plication on the cusp. Suture annuloplasty was introduced after 2009 for annular dilatation. RESULTS There were 17 consecutive patients. The median age at operation was 14 (2.8–18) years. Aortic valve morphology was tricuspid in 10 patients, bicuspid in 5 patients, unicuspid in 1 patient and a pulmonary autograft in 1 patient. Marfan syndrome, Loeys-Dietz syndrome and other connective tissue diseases were present in 11, 1 and 2 patients, respectively. Five patients had more than moderate aortic regurgitation. The median graft size used for root remodelling was 24 (18–26) mm. Cusp repair and annuloplasty were performed in 15 and 14 patients, respectively. The mean follow-up time was 6.5 ± 4.3 years. One patient with preoperatively severely depressed ventricular function died in the hospital from persistent heart failure. One patient (operated on before 2004) required aortic valve reoperation due to cusp prolapse. One patient with a unicuspid valve had developed moderate aortic regurgitation, and the other 14 patients had mild or less regurgitation. The median diameter of the sinus of Valsalva at the last follow-up was 36 (30–43) mm, Z-score of 1.5 (−3.5 to 3.9). CONCLUSIONS Root remodelling can be performed in children with favourable results by appropriate cusp repair and annuloplasty.

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