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Aortic regurgitation that appears or worsens during or after an episode of infective endocarditis or aortic dissection may lead to acute severe LV failure or subacute progression over weeks or months The former usually presents as pulmonary edema; surgical replacement of the valve is indicated even during active infection These patients may be transiently improved or stabilized by vasodilators Chronic regurgitation has a long natural history, but the prognosis without surgery becomes poor when symptoms occur Since aortic regurgitation places both a volume and afterload increase on the LV, medications that decrease afterload can reduce regurgitation severity Current recommendations continue to advocate afterload reduction in aortic regurgitation, though the data are derived from very few patients, and its use remains controversial Most clinicians prescribe ACE inhibitors whenever the LV diastolic size is increased > 50 cm as shown on echocardiogram -Blocker therapy may slow the rate of aortic dilation in Marfan syndrome by reducing the dP/dt, though the slower heart rates

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FIGURE 3-8

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that result may theoretically increase the diastolic time and the amount of regurgitation per beat Patients with aortic regurgitation need to be monitored serially by echocardiography Surgery is indicated once symptoms emerge or for any evidence of LV dysfunction LV dysfunction in this situation can be defined by echocardiography if the EF is < 55% or if the LV end-systolic dimension is > 50 cm, even in the asymptomatic patient In addition, aortic root diameters of > 50 cm in Marfan or > 55 cm in non-Marfan patients are indications for surgery to avoid rapid expansion Although the operative mortality rate is higher when LV function is severely impaired, valve replacement or repair is still indicated, since LV function often improves and the long-term prognosis is thereby enhanced even in this situation The issues with AVR covered in the above section concerning aortic stenosis pertain here Currently, however, there are no percutaneous approaches to aortic regurgitation The choice of prosthetic valve for AVR depends on the patient s age and compatibility with warfarin anticoagulation The operative mortality rate is usually in the 3 5% range Aortic regurgitation due to aortic root disease requires repair or replacement of the root Though valve-sparing operations have improved recently, most patients with root replacement undergo valve replacement at the same time Root replacement procedures include the Ross procedure (moving the pulmonary valve to the aortic position and replacing the pulmonary valve with a homograft or, less commonly, bioprosthetic valve), the direct homograft for the aortic root and valve, and the Bentall procedure (the use of a Dacron sheath with a mechanical or bioprosthetic valve sewn in place) Root replacement in association with valve replacement requires reanastomosis of the coronary arteries, and thus the procedure is more complex than valve replacement alone Following surgery, LV size usually decreases and LV function generally improves even when the baseline EF is depressed.

Enriquez-Sarano M et al Clinical practice Aortic regurgitation N Engl J Med 2004 Oct 7;351(15):1539 46 [PMID: 15470217] Evangelista A et al Long-term vasodilator therapy in patients with severe aortic regurgitation N Engl J Med 2005 Sep 29;353(13):1342 9 [PMID: 16192479] Scognamiglio R et al Long-term survival and functional results after aortic valve replacement in asymptomatic patients with chronic severe aortic regurgitation and left ventricular dysfunction J Am Coll Cardiol 2005 Apr 5;45 (7):1025 30 [PMID: 15808758]

Tricuspid stenosis is usually rheumatic in origin, though in the United States, tricuspid stenosis is more commonly due to tricuspid valve repair or replacement or to the carcinoid syndrome than to rheumatic fever Tricuspid regurgitation frequently accompanies the lesion It should be suspected when right heart failure appears in the course of mitral valve disease or in the postoperative period after tricuspid valve repair or replacement

Tricuspid stenosis is characterized by right heart failure and hepatomegaly, ascites, and dependent edema A giant a wave is seen in the JVP, which is elevated (Table 10 1) The typical diastolic rumble along the lower left sternal border mimics mitral stenosis, though the rumble increases with inspiration In sinus rhythm, a presystolic liver pulsation may be found

In the absence of atrial fibrillation, the ECG reveals RA enlargement The chest radiograph may show marked cardiomegaly with a normal PA size A dilated SVC and azygous vein may be evident The normal valve area of the tricuspid valve is 10 cm2, so significant stenosis must be present to produce a gradient Hemodynamically, a mean diastolic pressure gradient of > 5 mm Hg is considered significant, though even a 2 mm Hg gradient can be considered abnormal This can be demonstrated by echocardiography or at cardiac catheterization

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