Aortic Valve Insufficiency

Author: Fawwaz Shaw, M.D. 
Institution: University of Washington Medical Center
Date: November 2013
Date Reviewed: March 2024
Learning Domain: Adult Cardiac Surgery  
Learning Objective: Evaluation of and surgical decision making associated with acute Aortic Valve Insufficiency 

 

 

History

  • HPI: 33 y/o lady who presented with fever of 102.5°F, malaise and chills. She additionally reported one instance of acute blurry vision which resolved spontaneously and b/l upper arm weakness.
  • PMHx: negative
  • PSHX: C/Section 6 months ago.
  • Social Hx: Negative tobacco, EtoH or Illicit substances. Works as a loan officer.
  • Medications: None
  • Family Hx: Diabetes Mellitus

 

 

Physical Exam

  • Vital signs: 99/46; HR:98; Afebrile; 97% on RA
  • No focal neurologic deficits.
  • Normal S1, S2; Diastolic murmur. Non displaced PMI. No gallops / heaves.
  • Lung fields: rales in bases, without rhonchi.
  • No extremity edema 
  • Bilateral upper extremity weakness.

 

 

Labs

  • WBC: 14.8
  • Hct: 23%
  • Creatinine: 1.7
  • Electrolytes within normal ranges.
  • Mildly elevated ALT: 72 and Alk Phos: 253.
  • INR: 1.1
  • Blood culture: Group B beta hemolytic Strep

 

 

EKG

Chest X-Ray

Echocardiogram 1

Echocardiogram 2

 
 
 

ECHO Findings

  • Severe Aortic regurgitation.
  • Eccentric but broad regurgitant jet.
  • Poorly visualized leaflets with probable vegetation on leaflet.
  • LV size at upper limits of normal.
  • Hyperdynamic function.

 

 

Additional work up?

  • MRI Brain: Left parietal microinfarction.
  • CT A/P: No evidence of renal, splenic or other embolic disease.

 

 

Outcome

  • Underwent urgent AVR
  • Pericardial reconstruction of small root abscess (1x1 cm, located on the noncoronary side of the R coronary artery).
  • 19 mm Regent St. Jude mechanical prosthesis.
  • Discharged post operative day #9.
  • Uncomplicated post operative course.

 

 

Discussion Points

  • Pre-operative work-up
  • Anesthesia considerations in acute AI
  • Timing / urgency of Intervention
  • Pathophysiology of Acute AI
  • Patient / prosthetic mismatch
  • Operative management 
    • LV Vent / Myocardial protection / Root abscess
  • Optimal Valve Choices
    • Homograph / Mechanical vs Tissue valve

 

 

Classification of AI

 

 

Learning Points

  • Acute AI differs from Chronic AI 
  • Treatment of acute AI is urgent surgery.
  • Operation can be  dependent on etiology (e.g endocarditis vs. dissection vs. trauma)
  • Patients can be (acutely) very ill