Aortic Regurgitation Patients Research Articles

Determinants of anterior mitral leaflet fluttering in pure aortic regurgitation from pulsed Doppler study of the early diastolic interaction between the regurgitant jet and mitral inflow

Fluttering of the anterior mitral leaflet may be absent in patients with moderate to severe aortic regurgitation (AR), suggesting that the volumetric severity of AR alone does not determine the presence or absence of abnormal diastolic mitral valve motion. Fifteen patients with moderate to severe AR and normal mitral valves, 9 of whom demonstrated anterior mitral leaflet fluttering, were studied to elucidate the determinants of abnormal anterior mitral leaflet motion in these patients. Pulsed Doppler mapping of the flow-velocity disturbance of AR demonstrated its presence in the third of the left ventricular outflow tract adjacent to the anterior mitral leaflet in 8 of 9 patients with anterior mitral leaflet fluttering and none of the 6 patients without anterior mitral leaflet fluttering (p < 0.02). The impact of this regurgitant jet on early diastolic transmitral inflow was examined with pulsed Doppler in these 2 groups of patients with AR and in age-matched control subjects. Deceleration of early diastolic transmitral filling was slower in patients with AR and anterior mitral leaflet fluttering than in age-matched control subjects (283 ± 107 vs 457 ± 176 cm/s 2, p < 0.02), whereas it was not significantly different from controls in AR patients without anterior mitral leaflet fluttering. This resulted in significant prolongation of the duration of early diastolic transmitral filling in patients with AR and anterior mitral leaflet fluttering (297 ± 93 vs 203 ± 44 ms for age-matched control subjects, p < 0.02), which was not observed in patients with AR who did not have anterior mitral leaflet fluttering. Thus, in patients with moderate to severe AR, fluttering of the anterior mitral leaflet occurs in a subset of patients in whom the flow-velocity disturbance is directed onto the anterior mitral leaflet, resulting in alterations of early diasolic mitral flow velocities compatible with relative obstruction to mitral inflow.

Rest versus Exercise Ejection Fraction and the Decision to Perform Valve Replacement in Aortic Regurgitation

To study the relationship between left ventricular ejection fraction (LVEF) and the decision to perform aortic valve replacement, the correlates of undergoing valve replacement were studied in 56 asymptomatic or mildly symptomatic patients with isolated severe chronic aortic regurgitation (AR) undergoing exercise radionuclide angiography. The need for valve replacement was not indicated on clinical grounds, because symptoms were either mild or absent. Of a variety of noninvasive laboratory variables, stepwise logistic regression analysis showed the rest LVEF to be the best correlate of performing valve replacement. Valve replacement was performed in 24 (43 %) of the patients including 5% of AR patients with rest LVEF of 0.50 or more, 40% of patients with rest LVEF of 0.41-0.49, and 88% of patients with rest LVEF of 0.40 or less, p < 0.001. Of the 20 patients within the intermediate rest LVEF range of 0.41-0.49, the 8 undergoing valve replacement had a similar rest LVEF, but a lower exercise LVEF and older age, compared to the 12 not undergoing valve replacement. In conclusion, rest LVEF alone strongly correlates with the decision to perform valve replacement in asymptomatic or mildly symptomatic AR. In the higher and lower LVEF ranges, the rest value is the best correlate of whether the patient will have surgery and little or no additonal information is provided by exercising the patient. Only in the intermediate LVEF range is this decision unpredictable by the rest value. Physicians appear to consider rest LVEF a powerful prognosticator as evidenced by the decision-making patterns observed.

Factors influencing the variations of ejection fraction during exercise in chronic aortic regurgitation.

The influence of left ventricular volume variations and regurgitant fraction variations upon left ventricular ejection fraction during exercise was examined using equilibrium radionuclide angiography in patients suffering from aortic regurgitation. Ejection fraction (EF), regurgitant fraction (RF), end diastolic volume (EDV) and end systolic volume (ESV) variations from rest to peak exercise were determined in 44 patients suffering from chronic aortic regurgitation (AR) and in 8 healthy volunteers (C). In C, EF increased (+0.10 +/- 0.03, P less than 0.01) and ESV decreased significantly (-23% +/- 12%, P less than 0.01), RF and EDV did not vary significantly. In AR patients, EF, EDV and ESV did not vary significantly because of important scattering of individual values. Changes in EF and ESV were inversely correlated (r = -0.79, P less than 0.01) and RF decreased significantly (-0.12 +/- 0.10, P less than 0.01). Volumes and EF changes during exercise occurred in three different ways. In a 1st subgroup of 7 patients, EF increased (+0.09 +/- 0.03, P less than 0.05) in conjunction with a reduction of ESV (-24% +/- 12%, P less than 0.05) without a significant change in EDV. In a 2nd group of 22 patients, EF decreased (-0.04 +/- 0.07, P less than 0.01) in association with an increase in ESV (+17% +/- 16%, P less than 0.01) and no change in EDV. In a 2nd group of 22 patients, EF decreased (-0.04 +/- 0.07, P less than 0.01) in association with an increase in ESV (+17% +/- 16%, P less than 0.01) and no change in EDV. In a 3rd subgroup of 15 patients, EF decreased (-0.02 +/- 0.06, P less than 0.01) despite a reduction in ESV (-7% +/- 6%, P less than 0.01) because of a dramatic EDV decrease (-10% +/- 6%, P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Angina pectoris and coronary artery disease in isolated, severe aortic regurgitation

Seventy-eight patients with isolated, severe aortic regurgitation (AR) were studied retrospectively to determine the prevalence of angiographically significant coronary artery disease (CAD) and its relation to angina pectoris (AP). Angiographically, significant CAD was present in 29 of 78 patients (37%), and 36 patients (46%) had AP. Twenty-one of 36 patients (58%) with AP and 8 of 42 patients (19%) without AP had angiographically significant CAD. AP as a predictor of significant CAD had a sensitivity of 73%, specificity of 69% and a risk ratio of 3:1. The predictive accuracy of detecting CAD in the absence of AP was 81%. The benefit from concomitant coronary artery bypass grafting at the time of aortic valve replacement for AR has not been clearly demonstrated; therefore, routine coronary angiography is still recommended for all AR patients older than 40 years undergoing aortic valve replacement.

Echographic early systolic partial closure (notching) of the aortic valve in congestive cardiomyopathy

We investigated the prevalence and significance of aortic valve early systolic partial closure (notching) in congestive cardiomyopathy by reviewing clinical and M-mode echocardiographic findings in 33 patients. We also compared their echocardiographic aortic root and valve findings to those in 17 aortic regurgitation patients and 24 normal subjects. Thirteen cardiomyopathy patients (39%) exhibited aortic valve partial closure—similar to the prevalence in the aortic regurgitation (41%) and normal (33%) groups. However, patients with dilated cardiomyopathy and aortic valve notching exhibited a higher mean percentage of partial closure (18% ± 10) than those with notching in either the aortic regurgitation (8% ± 9) or normal (5% ± 2) group. There was no significant difference in age, body surface area, left ventricular dimension, systolic function, or presence of mitral regurgitation between cardiomyopathy patients with and without aortic valve notching, but the former had slightly greater aortic root dimensions and maximal aortic leaflet separation. Although the reason for this difference is unknown, a wider aortic root may result in low-pressure areas bordering the aortic flow stream during early systole, which may favor partial aortic valve closure.

Radionuclide angiographic evaluation of left ventricular function by resting ejection rate during the first third of systole in patients with chronic aortic regurgitation

In previous studies the rate of left ventricular (LV) volume change during the first third of systole was shown to be a more sensitive index of cardiac performance than ejection fraction (EF) in coronary disease. To test the hypothesis that a noninvasive index of the ejection rate in early systole can also identify subtle abnormalities of LV performance in aortic regurgitation (AR), the rate of change of LV counts during the first third of systole was measured by first-pass radionuclide angiography (RNV) in 34 AR patients and in 10 normal controls. By least squares analysis a straight line was fit to the LV counts obtained at 0.025 second intervals during the first third of systole; the slope was divided by the average counts in the first third to give a rate constant (RC) proportional to LV volume change during early systole. The AR patients were divided into two groups based upon the response of EF to exercise (ΔEF). A normal response was defined as a rise equal to or greater than 5%. Group 1 comprised 19 AR patients with a normal EF response to exercise (from 60 ± 9% to 70 ± 9%), and group 2 comprised 15 AR patients with an abnormal EF response to exercise (from 58 ± 9% to 52 ± 10%). The RC obtained at rest was 9.4 ± 2.8 for group 2, significantly lower than for group 1 (15.6 ± 3.9) or controls (14.9 ± 2.6) ( p < 0.01). Using an RC of 12.0 as a cutoff, separation of the two AR groups was excellent ( p < 0.01) with only one group 1 patient with RC < 12.0 and two in group 2 with RC > 12.0. When RC was plotted vs EF for all 44 individuals, there was a significant direct relationship, r = 0.74 ( p < 0.01), but with wide confidence limits. These data indicate that a noninvasive index of the rate of LV volume change during the first third of systole can identify abnormal LV reserve in AR patients with normal EF at rest.

Radionuclide angiographic exercise left ventricular performance in chronic aortic regurgitation: Relationship to resting echographic ventricular dimensions and systolic wall stress index

Forty-five patients with chronic aortic regurgitation (AR) underwent first-pass radionuclide angiocardiography (RNA) at rest and during upright bicycle exercise, as well as M-mode echocardiography at rest. Abnormal left ventricular (LV) exercise reserve, defined by the absolute change in ejection fraction (EF), was present in 16 of 45 patients (36%). Seven of ten patients with abnormal resting EF (< 50%) and three of seven symptomatic patients had normal LV exercise responses. Patients with normal LV exercise reserve by RNA had LV dimensions by echo at end diastole (5.9 ± 0.2 vs 6.5 ± 0.3 cm, p = NS) and end systole (3.9 ± 0.2 vs 4.4 ± 0.3 cm, p = NS) comparable to those in patients with abnormal LV exercise reserve. However, the mean corrected LV end-diastolic (LVED) radius/wall thickness ratio was significantly greater in AR patients with abnormal LV exercise reserve than in those with normal LV exercise reserve (395 ± 15 vs 315 ± 16, p < 0.01). These data suggest that resting echocardiographic LV dimensions as well as the corrected echo LVED radius/wall thickness ratio have a variable relationship to RNA LV exercise performance in patients with chronic AR.

Clinical aspect of aortitis syndrome with special reference to the relation between prognosis and hypertension.

The present study was done to investigate the relation between the prognosis and hypertension, especially hypertension due to renal arterial stenosis, atypical coarctation of the aorta and aortic regurgitation in patients with aortitis syndrome. Sixty-five patients including 25 with normotension and 40 with hypertension who were hospitalized during the last 20 years were included in this study. Out of the 40 patients with hypertension, a cause of hypertension was found in 37 patients: renovascular hypertension alone in 13, renovascular hypertension with atypical coarctation in 11, renovascular hypertension and aortic regurgitation in 2, atypical coarctation alone in 5, aortic regurgitation alone in 5 and all of the three in the remaining one. Thirty-two hypertensive patients out of 40 were treated with antihypertensive drugs and the remaining 8 underwent surgical operation (renal vascular repair in 6 and nephrectomy in 2 for relief of hypertension. In the present data, 13 out of 40 patients with hypertension died despite of the treatment, while only one out of 25 patients with normotension died. According to the mortality in each type of cardiovascular lesion, 6 patients died out of 13 with renovascular hypertension alone, 5 patients died out of 11 with renovascular hypertension associated with atypical coarctation and 2 patients with renovascular hypertension associated with aortic regurgitation died. In contrast, there was no death in hypertensive patients with aortic regurgitation alone or atypical coarctation of the aorta alone. These results indicate that hypertension, especially renovascular hypertension is one of the major determinant of the prognosis in the patient with aortitis syndrome.

Aortic valve replacement combined with myocardial revascularization. Late clinical results and survival of surgically-treated aortic valve patients with and without coronary artery disease.

From 1967 through 1973, 80 consecutive patients underwent simultaneous aortic valve replacement (AVR) and coronary bypass grafting. Fourteen (18%) experienced no angina pectoris and had no history or electrocardiographic evidence of coronary atherosclerosis. Seven of these 14 had severe multiple vessel disease. All operations were performed under normothermic conditions without coronary perfusion. Seven patients (9%) died during operation. Intra-operative myocardial infarction was documented in eight (10%). After a mean follow-up of 35 months, overall mortality was highest in aortic regurgitation patients [seven of 13 (54%)] compared to aortic stenosis [17 of 54 (31%)] (P less than 0.07), and mixed pathology [1 of 13 (8%)]. Thirty-one of 34 (91%) grafts in 25 patients were patent an average of 12 months postoperatively. After 42 months a 65% actuarial survival was found in the combined AVR and graft(s) series versus a 76% survival in 300 AVR patients proven by angiography not to have severe coronary atherosclerosis.

Ankylosing spondylitis and aortic regurgitation. Description of the characteristic cardiovascular lesion from study of eight necropsy patients.

Clinical and cardiovascular necropsy findings are described in eight patients with combined ankylosing spondylitis and aortic regurgitation. All were men (aged 34-55 years), each had peripheral arthritis in addition to spondylitis, all had severe congestive failure, and six had conduction disturbances. In three patients aortic regurgitation was present before distinctive radiologic changes of ankylosing spondylitis were apparent and only two patients had advanced arthritic changes of ankylosing spondylitis. Thus, cardiac dysfunction may be present before signs of spondylitis are apparent, and aortic regurgitation may be severe when signs of spondylitis are minimal. A characteristic cardiovascular morphologic abnormality was present in each patient. The aortic valve cusps and the aorta behind and immediately above the sinuses of Valsalva were thickened, the latter by dense adventitial scar tissue and by intimal fibrous proliferation. In each patient the scar tissue in the root of aorta extended below the base of aortic valve to produce a subaortic fibrous ridge. The subaortic bump involves the base of anterior mitral leaflet and may cause mitral regurgitation. Extension of the fibrous scar into ventricular septum may cause heart block. The distinctive cardiovascular morphologic findings in patients with ankylosing spondylitis clearly separate this condition from syphilis and other entities associated with aortic regurgitation.

Preoperative assessment of aortic regurgitation in patients with mitral valve disease ∗

When open operations are performed for the repair of malformations of the mitral valve, the associated aortic regurgitation may prove a serious technical handicap. It is desirable, therefore, to determine as precisely as possible before operation, the presence and severity of any aortic reflux which may be encountered when the left atrium is opened. Accordingly, aortic regurgitation assessed by the commonly employed clinical, hemodynamic and angiographie features was compared with the degree of aortic reflux encountered during operation in 156 patients in whom open operations on the mitral valve were performed. The intensity of the murmur of aortic regurgitation, the level of the arterial diastolic blood pressure, and the arterial pulse pressure were found not to correlate accurately with the amount of aortic reflux encountered at operation. However, the absence of the murmur usually precluded troublesome aortic reflux, and the combination of a diastolic blood pressure greater than 70 mm. Hg and an arterial pulse pressure less than 40 mm. Hg excluded the presence of more than trivial aortic regurgitation at operation. Cineaortographic data provided the most precise means for the prediction of operative aortic reflux. Patients without cine evidence of aortic regurgitation had none at operation; those with mild aortic regurgitation rarely had troublesome reflux during bypass; half of the patients with moderate aortic regurgitation had bothersome operative aortic reflux, while nearly all of those with marked aortic regurgitation on cine study exhibited severe reflux during bypass and required aortic valve replacement. On the basis of these findings, it is our policy to perform preoperative cineaortographic studies in all patients with mitral valve disease who exhibit decrescendo diastolic murmurs along the sternal border.

The preoperative assessment of aortic regurgitation in patients with mitral valve disease

The preoperative assessment of aortic regurgitation in patients with mitral valve disease