Acute Valvular Regurgitation

Abstract

HomeCirculationVol. 119, No. 25Acute Valvular Regurgitation Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBAcute Valvular Regurgitation Karen K. Stout, MD and Edward D. Verrier, MD Karen K. StoutKaren K. Stout From the University of Washington, Seattle. Search for more papers by this author and Edward D. VerrierEdward D. Verrier From the University of Washington, Seattle. Search for more papers by this author Originally published30 Jun 2009https://doi.org/10.1161/CIRCULATIONAHA.108.782292Circulation. 2009;119:3232–3241Acute severe valvular regurgitation is a surgical emergency, but accurate and timely diagnosis can be difficult. Although cardiovascular collapse is a common presentation, examination findings to suggest acute regurgitation may be subtle, and the clinical presentation may be nonspecific. Consequently, the presentation of acute valvular regurgitation may be mistaken for other acute conditions, such as sepsis, pneumonia, or nonvalvular heart failure. Although acute regurgitation may affect any valve, acute regurgitation of the left-sided valves is more common and has greater clinical impact than acute regurgitation of right-sided valves.Data to guide appropriate management of patients with acute regurgitation are sparse; there are no randomized trials, and much of the literature describes either small series or the experiences of specific centers. Despite these limitations, the available data are sufficient to allow identification of general principles as well as development of applicable guidelines from both the American College of Cardiology/American Heart Association and European Society of Cardiology. The guidelines recommend valve surgery for symptomatic patients with aortic or mitral regurgitation, including those with acute regurgitation.1–3 The data and guidelines emphasize overarching clinical principles, including the need for a high clinical suspicion of acute regurgitation, timely use of echocardiography, and, in the majority of patients, rapid progression to surgery.CausesCauses of acute regurgitation overlap with causes of chronic regurgitation and vary depending on the valve affected (Table 1). Endocarditis may affect either the aortic or mitral valve, whereas other causes are unique to the specific valve involved. The majority of causes of acute regurgitation present as an acute or subacute event. However, acute regurgitation can occur in patients with chronic regurgitation, when regurgitant severity is exacerbated by factors such as coronary ischemia, chordal rupture, or leaflet perforation from endocarditis. Acute regurgitation of either the aortic or mitral valve may result from procedural complications of percutaneous valve procedures. In addition, acute prosthetic valve regurgitation is seen more frequently as more patients undergo valve surgery. Acute prosthetic valve regurgitation is usually due to a tear of a bioprosthetic leaflet4 or thrombosis of a mechanical valve, although perivalvular regurgitation can occur, particularly in prosthetic valve endocarditis. Table 1. Causes of Acute RegurgitationAortic RegurgitationMitral Regurgitation*“Functional” causes of mitral regurgitation.EndocarditisChordal ruptureAortic dissection (type A)EndocarditisRuptured fenestrationPapillary muscle ruptureBlunt chest traumaPapillary displacement due to ischemia*Prosthetic valve dysfunctionAcute rheumatic fever with carditisAcute cardiomyopathy*Prosthetic valve dysfunctionAcute aortic regurgitation is most commonly due to endocarditis, but there are a variety of less common causes as well. Aortic dissection, whether due to Marfan syndrome, bicuspid aortic valve, or atherosclerotic disease, may present with aortic regurgitation. Blunt trauma may result in leaflet rupture.5 Another less common cause is rupture of a fenestration in the aortic leaflet.6Acute mitral regurgitation may result from either “organic” or “functional” causes. Organic causes are those that result in permanent structural disruption of the valve, such as leaflet perforation from endocarditis, chordal rupture in myxomatous valve disease, or papillary muscle rupture due to myocardial infarction. Functional mitral regurgitation results from abnormalities of the left ventricle, such as cardiomyopathies in which the papillary muscles are laterally displaced, or acute ischemia, in which an akinetic wall segment and papillary muscle impair mitral valve closure. The distinction between organic and functional causes is an important one because treatment of organic causes requires surgical repair, whereas functional causes may improve with treatment of the underlying myocardial ischemia, infarction, or cardiomyopathy.Functional mitral regurgitation is more often chronic than acute. However, processes that result in rapid decline of ventricular function may cause acute functional mitral regurgitation as part of the presentation of acute heart failure. Examples include myocarditis or rapidly developing cardiomyopathies such as Takotsubo cardiomyopathy (left apical ballooning) and peripartum cardiomyopathy.7–9 Emphasizing the variability in pathological process, a study demonstrated that mitral regurgitation in Takotsubo cardiomyopathy can result from outflow tract obstruction and systolic anterior mitral leaflet motion due to apical ballooning with preserved basal ventricular function.9 Rheumatic carditis can cause acute mitral regurgitation through a combination of leaflet inflammation and myocardial dysfunction, with some data suggesting that the degree of valve dysfunction drives outcomes.10 Although uncommon in industrialized nations, acute rheumatic carditis remains a significant issue in developing countries.11PathophysiologyMost clinicians are familiar with the pathophysiology and hemodynamic impact of chronic regurgitation, but the stark differences between acute and chronic regurgitation are important to understand to make an accurate diagnosis of acute regurgitation. Chronic regurgitation of either the aortic or mitral valve affords time for the ventricle to dilate to accommodate the regurgitant volume. This adaptation maintains forward stroke volume and cardiac output despite the regurgitant volume. Correspondingly, left ventricular end-diastolic pressure remains normal unless there is coexistent pathology that impairs diastolic function.The lack of time for adaptation to additional blood volume leads to the cascade of events typical of acute regurgitation. Acute aortic and mitral regurgitation share some common hemodynamic sequelae, despite the differences in pathogenesis and valve location within the circulation. In both circumstances, the left ventricle is not able to adequately compensate for the regurgitant volume, and excessive backward blood flow impairs forward stroke volume. Compensatory tachycardia may preserve cardiac output initially, but eventually hypotension, organ failure, and other evidence of cardiogenic shock will develop. Pulmonary capillary wedge pressure increases abruptly and pulmonary edema develops, although by different mechanisms depending on the valve involved. Notably, acute exacerbation of chronic regurgitation may result in similar hemodynamic changes.Aortic Valve RegurgitationAcute aortic regurgitation differs from chronic aortic regurgitation in several important ways. In acute aortic regurgitation, normal ventricular size results in a marked increase in end-diastolic pressure relative to the regurgitant volume. Impaired forward stroke volume yields a decreased systolic pressure and a narrow pulse pressure.12,13 Although there is some degree of compensation by a Frank-Starling mechanism, the ventricle is functioning on a steep pressure-volume curve because of the lack of chamber dilation. This contrasts with chronic regurgitation, in which end-diastolic pressures are relatively low, and the additional stroke volume manifests as an increased systolic pressure (Table 2). Therefore, reliance on pulse pressure as an indicator of regurgitation may significantly underestimate the severity of acute aortic regurgitation. In chronic aortic regurgitation, increased systolic pressure results in increased afterload. This is not seen in acute regurgitation given the low stroke volume. However, if acute regurgitation has resulted in shock, sympathetic activation and the renin-angiotensin cascade may result in increased systemic vascular resistance. Table 2. Comparison of Findings in Acute and Chronic Severe RegurgitationAcuteChronicN indicates normal; ↑, increased from normal; ↓, decreased from normal; CVP, central venous pressure.Aortic regurgitation Hemodynamics Cardiac output↓N Pulse pressureN ↓↓ Systolic pressure↓↑ Left ventricular end-diastolic pressure↑ ↑N Left ventricular sizeN↑ Examination Diastolic murmurSoft, earlyHolodiastolic, decrescendo S1SoftNormal S2Loud P2Normal S3PresentAbsentMitral regurgitation Hemodynamics Cardiac output↓N Ejection fractionN ↓N ↑ Left ventricular end-diastolic pressure↑ ↑N Left atrial complianceN↑ Left ventricular sizeN↑ Examination MurmurSoft, decrescendoHolosystolic S3May be presentAbsent V waves of CVPMay be presentAbsentAbnormal mitral valve function due to acute hemodynamic changes may further impair stroke volume. Marked elevation of left ventricular diastolic pressure can cause early closure of the mitral valve, and tachycardia will limit mitral inflow, resulting in decreased ventricular filling.14The presence of preexisting chronic aortic regurgitation and ventricular enlargement may blunt the hemodynamic impact of acutely worsened regurgitation. Conversely, preexisting disease processes that impair diastolic function, such as hypertension or aortic stenosis, may result in markedly more dramatic clinical presentation of acute aortic regurgitation.Coronary ischemia may develop as a consequence of aortic regurgitation. Decreased diastolic coronary flow decreases myocardial perfusion, whereas elevated end-diastolic pressures and tachycardia increase myocardial oxygen demand. This supply-demand mismatch is obviously further exacerbated if obstructive coronary lesions are present or if aortic dissection impairs coronary flow.Acute Mitral RegurgitationChronic regurgitation increases left atrial size and compliance, and, accordingly, left atrial pressures will be normal despite the regurgitant volume. Conversely, acute mitral regurgitation increases volume into a normally compliant left atrium, resulting in a marked increase in left atrial pressure (Table 2).2 A significant V wave may be evident in either condition, although it is more pronounced in acute regurgitation. Because of the increased left atrial pressure from acute mitral regurgitation, pulmonary edema is a common consequence. Preexisting conditions may affect tolerance of acutely increased left atrial and left ventricular volume. Patients with a history of chronic mitral regurgitation and preserved ventricular function may tolerate the marked increase in volume better, whereas patients with impaired ventricular function may quickly decompensate with acute worsening of mitral regurgitation. Those patients with pulmonary edema associated with ST-segment elevation myocardial infarction often have coexistent mitral regurgitation, with often underappreciated severity and a poor prognosis.15 As with acute aortic regurgitation, there is some degree of initial compensation afforded by increased preload, but the inability of the ventricle and atrium to accommodate the increased volume results in marked increase in left ventricular end-diastolic and left atrial pressures.Clinical PresentationThe majority of patients with acute aortic or mitral regurgitation will present with dyspnea, hemodynamic instability, and symptoms of shock, including weakness, dizziness, and altered mental status. Symptoms at presentation may also reflect the underlying pathogenesis of acute regurgitation, such as severe chest pain from aortic dissection or fever from endocarditis. A subset of patients with acute mitral regurgitation may present solely with new-onset dyspnea, without evidence of impending cardiovascular collapse, and may therefore be misdiagnosed with a noncardiogenic pulmonary process or heart failure from another cause (Figure 1). Download figureDownload PowerPointFigure 1. Transesophageal echocardiography of acute mitral regurgitation due to perforation of the mitral leaflet from endocarditis. A 70-year-old man presented with hypotension and dyspnea 3 weeks after treatment for infection of an indwelling venous catheter. He was in shock, was intubated, and was begun on pressors and antibiotics. He was clinically believed to have sepsis and pneumonia. His clinical condition did not improve, and although his examination did not suggest a cardiac abnormality, because of concerns about his prior catheter infection, an echocardiogram was ordered. The transthoracic images showed severe mitral regurgitation with normal left ventricular size and function. A vegetation was seen on the mitral leaflet and there was an apparent perforation. He was taken emergently to the operating room for mitral valve replacement; this transesophageal echocardiogram was obtained before initiation of cardiopulmonary bypass. The image shows a large vegetation and associated leaflet perforation, resulting in significant regurgitation. VEG indicates vegetation; MV, mitral valve; MR, mitral regurgitant jet; AV, aortic valve; LV, left ventricle; and LA, left atrium.On examination, tachycardia, hypotension, peripheral vasoconstriction, and other evidence of cardiogenic shock are common. As listed in Table 2, examination findings typically seen in chronic regurgitation may be absent or subtle. For the aforementioned reasons, the findings of chronic regurgitation related to ventricular enlargement, such as apical displacement, are typically absent, and murmurs are frequently soft. The presence of tachycardia and tachypnea further impairs the detection of faint murmurs.In acute aortic regurgitation, the rapid equilibration of left ventricular and aortic diastolic pressures results in a faint early diastolic murmur, in contrast to the louder decrescendo diastolic murmur of chronic significant aortic regurgitation. Early closure of the mitral valve due to elevated left ventricular end-diastolic pressures yields a soft S1, lack of aortic leaflet coaptation during valve closure results in a soft A2, and, if pulmonary hypertension is present, there may be a loud P2, findings not typical of chronic regurgitation. The eponymous peripheral signs associated with chronic aortic regurgitation typically reflect increased pulsatility from increased stroke volume and wide pulse pressure. Because of the diminished stroke volume and decreased pulse pressure of acute aortic regurgitation, these signs are not typically present. With acute severe mitral regurgitation, rapid equilibration of ventricular and atrial pressures during systole results in a faint systolic murmur rather than the holosystolic murmur typically heard with chronic mitral regurgitation. Reliance on examination findings alone to diagnose acute regurgitation or estimate severity is fraught with potential error, and therefore additional diagnostic testing is needed.Diagnostic TestingElectrocardiography typically demonstrates sinus tachycardia with nonspecific ST- and T-wave abnormalities. Evidence of ischemic ST changes may be seen if regurgitation is mediated by ischemia or if the hemodynamic circumstances exacerbate coronary insufficiency.Chest x-ray will typically demonstrate a normal-sized left heart and pulmonary edema. Those patients with preexisting left ventricular dilation may have cardiomegaly, whereas those with aortic dissection may have a widened mediastinum. Rarely, acute mitral regurgitation may direct regurgitant flow preferentially to a single pulmonary vein, with edema seen most prominently in that lung segment.16 This finding is easily confused with pneumonia, particularly if the patient has endocarditis or is not profoundly ill.The diagnosis of acute regurgitation is made by echocardiography. The presence of severe aortic or mitral regurgitation and normal left ventricular size should immediately raise the possibility of acute regurgitation. Further suspicion should be raised if ventricular function appears normal or hyperdynamic because ejection fraction is typically not significantly decreased in acute regurgitation.17 Echocardiographic findings of acute severe aortic and mitral regurgitation are shown in Table 3. Quantitative measures of regurgitant severity that are useful in chronic regurgitation are less useful in acute regurgitation. Measures of effective regurgitant orifice area and regurgitant volume can be inaccurate in acute regurgitation, particularly in the face of tachycardia. Hemodynamic data have demonstrated the variability in effective regurgitant orifice area and regurgitant volume in acute regurgitation depending on afterload and loading conditions.18,19 Thus, rarely will quantitative measures contribute significantly to management decisions in acute regurgitation. Table 3. Echo Findings of Acute RegurgitationAortic RegurgitationMitral RegurgitationVena contracta >6 mmVena contracta >7 mmPressure 1/2 time <200 msReversed pulmonary vein flowHolodiastolic flow reversal in abdominal aortaDecreased aortic valve openingDisrupted mitral valve apparatusPremature mitral valve closureNormal left ventricular size and functionNormal left ventricular size and functionIn addition to assessment of severity and ventricular function, transthoracic echocardiography should also demonstrate the mechanism of regurgitation, such as dissection or ruptured mitral chordae. The acuity of regurgitation may be difficult to assess by echocardiography alone in patients with a history of chronic regurgitation because ventricular size is enlarged, and Doppler findings may be present because of chronic regurgitation. In these cases, comparison with prior studies and clinical examination of the patient will aid in determination of acuity.Color Doppler on transthoracic echocardiography may underestimate regurgitation severity, particularly if the jet is eccentric. Transesophageal echocardiography may be indispensable in identifying the severity and mechanism of regurgitation if a transthoracic study is inconclusive, particularly with prosthetic valve dysfunction. Additionally, transesophageal echocardiography is important in planning operative repair options, including identification of leaflet or annulus involvement, and in establishing annular size to guide valve replacement options. Particularly if one plans to use an aortic homograft or to evaluate the feasibility of a Ross repair, transesophageal echocardiographic data on annular size are important. However, if the transesophageal echocardiography results will not materially change the decision to pursue surgery, transesophageal echocardiography can be done in the operating room (Figures 1 and 2). Download figureDownload PowerPointFigure 2. Intraoperative view of leaflet perforation and vegetation. This image demonstrates the perforation and nearby vegetation, which resulted in severe valve destruction and mitral regurgitation. The valve was replaced with a tissue prosthesis, and the patient tolerated surgery well and was transferred to the intensive care unit in hemodynamically stable condition. Ventricular function was preserved, and the mitral prosthesis functioned well without evidence of recurrent infection.Cardiac catheterization is generally not indicated in the preoperative assessment of patients with acute regurgitation. The exception is patients with acute coronary syndromes complicated by acute mitral regurgitation, for whom revascularization alone may improve regurgitation or for whom both revascularization and mitral valve surgery are needed. For those patients without ischemia as a potential underlying mechanism of regurgitation, such as those with mitral regurgitation due to chordal rupture or aortic regurgitation, the time to obtain a cardiac catheterization and the contrast load may be poorly tolerated. For those with aortic dissection, cardiac catheterization is rarely needed and may worsen dissection. Additional imaging to evaluate possible underlying causes of acute regurgitation, such as computed tomography or magnetic resonance imaging, may be needed, particularly if aortic dissection is a concern not addressed fully by echocardiography.20Rapid diagnosis is of the utmost importance because the mortality of acute severe regurgitation is high if untreated. Therefore, any diagnostic modality needed to make an accurate timely diagnosis should be used, but once the diagnosis is made, definitive treatment should not be delayed for diagnostic studies that will not significantly alter the course of care. Acute coronary syndromes and ischemia benefit diagnostically from cardiac biomarkers, and brain natriuretic peptide results can help to distinguish cardiac from noncardiac causes of dyspnea and shock. This is particularly true in those patients presenting with unilateral pulmonary edema.16TreatmentMedical TherapyThe treatment of acute aortic regurgitation is surgery to repair or replace the valve. Medical therapy may be used to stabilize the patient en route to surgery; however, surgery should not be delayed in favor of efforts at medical management.16 While the surgical team is being readied, vasodilators such as nitroprusside may be used to improve forward flow, and inotropes such as dobutamine may improve cardiac output. Medical therapy is not a substitute for surgery, however.21,22 Intra-aortic balloon pump use is contraindicated in acute aortic regurgitation because balloon inflation during diastole is detrimental to left ventricular hemodynamics.Patients with organic causes of mitral regurgitation are similar to those with acute aortic regurgitation. Although supportive therapy may provide some stability en route to the operating room, the fundamental abnormality is structural and requires surgical intervention. Thus, the most important distinction in assessing acute mitral regurgitation is determining the underlying cause. If organic, with disruption of the normal valve structure, surgery is the mainstay of therapy. If functional, medical therapy may be sufficient to avoid operative intervention; however, if medical therapy fails, surgical options need to be reexplored. Additionally, revascularization is a necessity in those patients undergoing surgery for acute mitral regurgitation if significant obstructive coronary disease is present. Unlike in acute aortic regurgitation, the intra-aortic balloon pump may be beneficial in acute mitral regurgitation.Medical therapy for patients with acute functional mitral regurgitation is directed at the underlying pathophysiology. In patients with ischemia or infarction, restoration of blood flow to the affected territory may be sufficient to improve regurgitation. Data suggest that severe mitral regurgitation in patients with cardiogenic shock is not uncommon, approaching 7% of patients in the Should We Emergently Revascularize Occluded Coronaries in Cardiogenic Shock (SHOCK) registry, and that the presence of acute mitral regurgitation in these patients is a very poor prognostic sign, with an observed mortality of 55%, improving to only 39% in patients selected for emergency surgery.23 The SHOCK trial demonstrated that early revascularization improves outcomes at 6 months in patients with cardiogenic shock and acute myocardial infarction,24 and further analysis demonstrated the prognostic importance of mitral regurgitation in these patients. Short- and long-term survival was inversely related to the degree of mitral regurgitation, arguing for more aggressive treatment of those patients with significant mitral regurgitation in the setting of acute infarction, with improved mortality in those patients undergoing early revascularization.25 Thus, if surgical revascularization is needed, the presence of severe mitral regurgitation should encourage rather than discourage surgical intervention.In those with acute regurgitation in the setting of acutely developing or worsening cardiomyopathies, aggressive heart failure therapy may be sufficient to improve the degree of mitral regurgitation. In addition to pharmacotherapy, mechanical support may be of use in patients with functional mitral regurgitation. The intra-aortic balloon pump can be an effective support mechanism in patients with acute functional mitral regurgitation of any cause but is particularly useful for those patients with underlying myocardial ischemia or cardiomyopathy. The role of left ventricular assist devices is not well studied in acute mitral regurgitation but can be used in the setting of acutely decompensated heart failure not responsive to medical therapy.For patients with valve thrombosis resulting in acute regurgitation, thrombolytic therapy may be an alternative to surgery. However, both the American College of Cardiology/American Heart Association and European Society of Cardiology guidelines recommend surgery as first-line treatment in patients with significant symptomatic prosthetic valve dysfunction, with thrombolytics reserved for proven valve thrombosis when surgery is high risk or unavailable or if there is a small thrombus burden and few symptoms.1–3Surgical Treatment: Acute Aortic RegurgitationAnesthetic ConsiderationsAnesthetizing a critically ill patient with acute aortic regurgitation can be a significant challenge. Induction is particularly risky, and the surgical team should be present in the room at the time of induction, ready to initiate early cardiovascular support if necessary.The pathophysiology of acute aortic regurgitation presents unique challenges to the anesthesiologist. Low diastolic pressure, tachycardia, and increased wall stress may impair coronary flow, and if induction further reduces blood pressure, coronary ischemia may exacerbate patient instability. Consequently, the anesthesiologist must attempt to avoid tachycardia and hypotension during intubation and induction of anesthesia because there may not be latitude to accelerate care to compensate for worsened hypotension and coronary ischemia. Hemodynamic monitoring is also crucial, and in many cases monitoring lines will have been placed before arrival in the operating room. The rational use of inotropic drugs, vasoconstrictors, sedatives, and anesthetic agents is essential to ensure optimal outcomes.Surgical ConsiderationsIn the aortic position, surgical options are defined by the pathophysiology of disease, anatomy, and anticipated long-term outcomes. Myocardial protection is a significant concern in this setting because the incompetent aortic valve and possible associated aortic root pathology make antegrade cardioplegia ineffective or possibly dangerous. Reliable placement of a retrograde coronary sinus cannula for delivery of cardioplegia is essential. Adjuvant handheld cardioplegia can be delivered subsequently via coronary ostia after the aortic valve and root have been properly assessed. Additionally, use of a left ventricular vent, placed via the right superior pulmonary vein, may aid in ventricular decompression and induction of a diastolic arrest. Other protective adjuncts such as systemic hypothermia on cardiopulmonary bypass or topical cooling have been used frequently but have unclear overall value.Aortic Valve EndocarditisIntraoperative transesophageal echocardiography and direct assessment of annular involvement are important in planning the surgical procedure. Careful assessment of the annulus is essential to ensure that (1) it is intact and (2) there are no undrained abscesses. In cases of aortic annulus involvement, the use of a homograft is generally indicated (Figure 3). Although aortic homografts are also at risk for prosthetic valve endocarditis, the additional tissue included with the homograft, including the left ventricular outflow tract and the anterior leaflet of the mitral valve, is sometimes essential for successful aortic root reconstruction. In cases of endocarditis limited to the valve leaflets, leaflet excision and aortic valve replacement are indicated, without additional annular procedures. There is no evidence that a mechanical versus a bioprosthetic valve has a differential rate of infection after replacement for endocarditis.26Download figureDownload PowerPointFigure 3. Operative technique for replacement of the aortic valve and root in complicated aortic endocarditis with annular abscess. A, Technique of aortic root replacement and homograft reconstruction. The infected valve is excised, and all infected and necrotic tissue is radically debrided. The coronary ostia are preserved as buttons. B, The defect is reconstructed by suturing the homograft mitral valve leaflet below the level of the infection. From Sabik JF, Lytle BW, Blackstone EH, et al. Aortic root replacement with cryopreserved allograft for prosthetic valve endocarditis. Ann Thorac Surg. 2002;74:650–659. Modified from Sellke F, Swanson S, del Nido P, eds. Sabiston and Spencer, Surgery of the Chest. 7th ed. Amsterdam, Netherlands: Elsevier; 2005, copyright © 2005, with permission from Elsevier.In some centers, particularly in children, the use of a pulmonary autograft (Ross procedure) may be used. This is controversial, however. As with elective aortic valve surgery, the risk and benefits of the Ross repair are debatable. Theoretically, there is a benefit of providing a durable aortic valve replacement th