Aortic regurgitation

Hywel Davies reported of temporarily treatment of aortic regurgitation with a parachute valve mounted onto a catheter tip in 1965 (34). Twenty-seven years later Andersen and his colleagues described the first experience with a bioprosthetic valve attached to a wire-based stent and mounted on a balloon valvuloplasty catheter (35). In 2002, Alain Cribier performed the first transcatheter valve implantation in an elderly patient with inoperable aortic stenosis using a prototype of a stent-mounted, pericardial, tricuspid aortic valve (36). 

Singh JP, Evans JC, Levy D, et al. Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study). Am J Cardiol 1999 83 897-902. 

Aortic arch dissection can cause profound hypotension, with global, and sometimes boundary zone, cerebral ischemia or focal cerebral ischemia if the dissection spreads up one of the neck arteries. Clues to this diagnosis are anterior chest or interscapular pain, along with diminished, unequal or absent arterial pulses in the arms or neck and a normal electrocardiogram, unlike acute myocardial infarction, acute aortic regurgitation and pericardial effusion. 

This was an unusual study because patients enrolled for a different purpose were analysed mid-way through the study in response to withdrawal of fenfluramine. Exposure to fenfluramine in this study was relatively short (2-3 months) and the prevalences of mitral regurgitation and aortic regurgitation in this study were much lower than previously described (25). 

Using the FDA case definition of appetite-suppressant related valvulopathy, the prevalence was 31% (60/191) in a selected group of Mayo Clinic patients at Rochester (33). The most common finding was mild aortic regurgitation. Of asymptomatic patients 28% had abnormal... 

There is further evidence of the relation between the duration of treatment with fen-phen and the prevalence of valvular abnormalities (42). In 1163 patients who had taken anorexigens within the previous 5 years and 672 control patients who had not, valvular abnormalities primarily involved those who had taken anorexigens for more than 6 months, and predominantly resulted in mild aortic regurgitation. The study had some noteworthy limitations since fenfluramine has been withdrawn from use, a randomized trial was impossible also the lack of baseline echocardiograms before treatment implies that one cannot be certain that the valvular regurgitation developed subsequent to drug treatment. 

The small increase in prevalence of minor degrees of aortic regurgitation and mitral regurgitation in 941 patients treated with dexfenfluramine for 2-3 months was no longer present 3-5 months (median 137 days) after withdrawal (47). Echocardiograms were acquired using a standardized protocol and were assessed blindly. 

Kancherla MK, Salti HI, Mulderink TA, Parker M, Bonow RO, Mehlman DJ. Exhocardiographic prevalence of mitral and/or aortic regurgitation in patients exposed to either fenfluramine-phentermine combination or to dexfenfluramine. Am J Cardiol 1999 84(ll) 1335-8. 

A 48-year-old man with an inflammatory aneurysm of the ascending aorta and severe heart failure due to massive aortic regurgitation was given a continuous intravenous infusion of milrinone O.Smicrograms/kg/ minute (1). His pulmonary arterial pressure fell and his symptoms improved over 7 weeks while he was taking corticosteroids. The diseased tissue was successfully replaced at operation and the milrinone was tapered uneventfully. 

In a systematic review of 1279 patients taking fenfluramine, dexfenfluramine, or phentermine, evaluated in seven uncontrolled cohort studies, 236 (18%) and 60 (5%) had aortic and mitral regurgitation respectively (2). Pooled data from six controlled cohort studies yielded, for aortic regurgitation, a relative risk ratio... 

Unger P, Nortier J, Muniz Martinez MC, Plein D, Vandenbossche JL, Vereerstraeten P, Vanherweghem JL. High prevalence of fenfluramine-related aortic regurgitation in women with end-stage renal disease secondary to Chinese herb nephropathy. Nephrol Dial Transplant 2003 18 906-910... 

Figure 3.12 Male, 42 years old, with severe but not long-standing aortic regurgitation. Note the evident q wave in V5, the intrinsic deflection time (IDT) >0.07 s, the height of the R wave is >30 mm and the T wave is tall and peaked (14 mm). There is also a negative U wave.

Diastolic Aortic regurgitation 2nd to 4th LICS High Apex Blowing... 

Diastolic murmur (in absence of aortic regurgitation) Coronary artery stenosis Rare... 

Population-based echocardiographic studies in the United States estimate that about 2.5% of the population have moderate to severe valvular dysfunction (1). Of the cardiac valvular disease categories reported, mitral regurgitation was found to be the most prevalent (1.7%), followed by aortic regurgitation and stenosis (0.5% and 0.4% respectively), while mitral stenosis was the least common (0.1%). The incidence of heart disease increased with age (0.7% between age 18 and 44 and 13.3% in subjects 75 years or older). There was a 1.36-fold increase in overall adjusted mortality in patients with valvular dysfunction compared to those without (1). 

AR aortic regurgitation CCA common carotid artery ECA external carotid artery ICA internal carotid artery GI gastrointestinal LV left ventricular MR mitral regurgitation PMI point of maximal impulse TR tricuspid regurgitation ... 

Stiff joints, cloudy cornea, aortic regurgitation, normal intelligence, normal life-span... 

Type IV Morquio-Ullrich syndrome (probably more than one allelic form) Severe bone changes of distinctive type, cloudy cornea, aortic regurgitation Homozygous for Morquio-Ullrich gene Keratan sulfate Unknown... 

Of 40 patients with unexplained restrictive valvular disease and previous exposure to benfluorex, mean age 57 years, body mass index 30kg/m=, 35 of whom were women, 15 presented with severe heart failure [46 ]. The daily dose mean of benfluorex was 415 mg (cumulative dose 910 g) and the mean duration of therapy was 72 months. Common echocardiographic findings were thickening and retraction of the valve leaflets and the subvalvular apparatus. There was aortic regurgitation in 35 and mitral regurgitation in 33, with severe regurgitation in 29. In 31 cases more than one valve was involved. There was pulmonary arterial hypertension in 20 cases. 

Firth BG, Dehmer Gl, Nicod P, WiUerson IT, Hillis LD. Effect of increasing heart rate in patients with aortic regurgitation. Effect of incremental atrial pacing on scintigraphic, hemodynamic and thermodilution measurements. Am J Cardiol 1982 49 1860-1867. 

Meyer TE, Sareh P, Marcus RH, Patel J, Berk MR. Beneficial effect of atrial pacing in severe acute aortic regurgitation and role of M-mode echocardiography in determining the optimal pacing interval. Am J Cardiol 1991 67 398-403. 

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