01Approach to the Critical Patient/attcp60

Immediate priorities

›Acute vs chronic determination

›Acute severe AR is a surgical emergency

›Endocarditis, dissection, or trauma etiology

›Sudden dyspnea with hemodynamic collapse

›LV and aortic diastolic pressures equilibrate rapidly

›Chronic AR is insidious

›Compensated phase may last years

›Decompensation signals irreversible remodeling

›If acute severe AR suspected, emergent cardiac surgery activation

›Class I recommendation

›Do not delay for further workup

›Airway and breathing threats

›Acute pulmonary edema

›SpO2 < 90% on room air

›Flash edema from sudden volume overload

›Ventilation support

›NIV when not hypotensive

›Early intubation if cardiogenic shock

›Circulation threats

›Cardiogenic shock physiology

›SBP < 90 mmHg

›Cool extremities and tachycardia

›Forward flow failure

›Low diastolic pressure with coronary hypoperfusion

›Narrow effective stroke volume despite wide pulse pressure in chronic AR

Hemodynamic goals and devices

›Afterload and rate targets

02History/hx71

Onset and tempo

›Time course

›Acute presentation

›Sudden dyspnea and collapse

›Endocarditis, dissection, or trauma trigger

›Chronic presentation

›Insidious decline over years

›Duration of known murmur and prior echocardiograms

›Symptom progression

›Rate of decline

›NYHA functional class change

›Exercise tolerance trend

›Prior imaging

›Serial LV dimensions

›Documented valve morphology

Classic symptoms

›Exertional dyspnea

›Most common symptom of chronic decompensated AR

›Exercise tolerance limitation

›NYHA class quantification

›Orthopnea and PND

›Elevated LV filling pressures

›Decompensation marker

›Chest pain

›Reduced coronary perfusion from low diastolic BP

›May occur without coronary disease

›Worse with tachycardia

›Differentiate from dissection pain

03Physical Exam/exam62

Vital signs

›Pulse pressure

›Wide pulse pressure hallmark

›Elevated systolic and low diastolic BP

›Reflects large regurgitant stroke volume

›Decreasing diastolic BP

›Independent mortality risk factor

›Coronary hypoperfusion marker

›Hill's sign

›Leg SBP >= 30 mmHg higher than arm SBP

›Suggests severe AR

›Acute AR vitals

›Pulse pressure may not be wide

›LV has not dilated

›Subtle peripheral signs

›Tachycardia and low output predominate

Cardiac auscultation

›Diastolic murmur

›High-pitched blowing early diastolic decrescendo murmur

›Best at left sternal border

›Patient sitting up, leaning forward, end-expiration

›Right sternal border accentuation

›Suggests aortic root dilation etiology

›Soft and short murmur in acute AR

›Rapid pressure equilibration

›Easily missed

›Additional findings

›Austin Flint murmur

04Differential Diagnosis/ddx35

Life-threatening causes of acute AR

›Aortic dissection

›Type A dissection

›Tearing chest or back pain

›Asymmetric blood pressures

›New AR murmur with malperfusion

›ICD-10 I71.00 dissection of unspecified site

›Infective endocarditis

›New murmur with fever

›Janeway lesions and Osler nodes

›Splinter hemorrhages

›ICD-10 I33.0 acute and subacute infective endocarditis

›Traumatic valve injury

›Blunt chest trauma

›Deceleration mechanism

›Acute regurgitation onset

Murmur and syndrome mimics

›Diastolic murmur mimics

›Pulmonary regurgitation

›Graham Steell murmur in pulmonary hypertension

›Diastolic murmur at left sternal border

›Mitral stenosis

›Low-pitched apical diastolic rumble

›Opening snap

›Continuous or systolic mimics

›Patent ductus arteriosus

›Continuous machinery murmur

›Ruptured sinus of Valsalva aneurysm

05Laboratory Tests/lt36

Cardiac and heart failure markers

›BNP / NT-proBNP

›Elevated in decompensated AR with heart failure

›Useful for monitoring

›Correlates with filling pressures

›Serial trending

›Response to diuresis

›Baseline for surveillance

›Troponin

›Acute coronary syndrome in differential

›Acute AR with hemodynamic compromise

›Demand ischemia from low diastolic pressure

Infection and inflammation

›Endocarditis workup

›Blood cultures

›Two sets from separate sites

›Prior to antibiotics when feasible

›ESR and CRP

›Elevated in endocarditis or aortitis

›Nonspecific markers

›Complete blood count

›Anemia worsens AR hemodynamics

›Increases regurgitant fraction

›High-output contribution

›Leukocytosis

›Supports infective endocarditis

Etiologic and pre-surgical labs

›Specialized serology

06Diagnostic Tests/dt82

Scoring Systems

›ACC/AHA staging (2020)

›Stage A at risk

›Bicuspid valve or aortic root disease

›No regurgitation

›Stage B progressive

›Mild to moderate AR

›Normal LV function

›Stage C asymptomatic severe

›C1 normal LVEF > 55% and LVESD < 50 mm

›C2 LVEF <= 55% or LVESD > 50 mm

›Stage D symptomatic severe

›Exertional dyspnea, angina, or heart failure

›TTE severity criteria for severe AR

›Jet width >= 65% of LVOT

›Vena contracta > 0.6 cm

›Regurgitant volume >= 60 ml per beat

›Regurgitant fraction >= 50%

›Effective regurgitant orifice >= 0.3 cm2

›Pressure half-time < 200 ms

›Holodiastolic flow reversal in proximal abdominal aorta

›Functional and prognostic measures

›Global longitudinal strain

›GLS worse than -18% to -19% detects subclinical dysfunction

›Predicts adverse outcomes with preserved LVEF

›Exercise stress testing

›Unmask symptoms in asymptomatic severe AR

›Abnormal hemodynamic response

07Disposition/dispo29

Level of care

›ICU and emergent admission

›Acute severe AR

›Surgical emergency

›Operating room readiness

›Decompensated chronic AR

›Pulmonary edema or hypotension

›Cardiogenic shock

›New AR with acute etiology

›Suspected endocarditis

›Suspected aortic dissection

›Observation

›Borderline new moderate to severe AR

›LV parameters near surgical thresholds

›Borderline symptoms

Discharge and consultation

›Discharge criteria

›Stable chronic AR

›Stages A to C1

›Established follow-up plan

›Hemodynamic stability

›No acute etiology identified

›Adequate oral intake

›Specialist consultation triggers

›Cardiology

›All new moderate or greater AR for surveillance planning

›Cardiothoracic surgery

›LVEF <= 55%, LVESD > 50 mm, or symptomatic severe AR

08Treatment/t77

Acute severe AR stabilization

›Emergent surgery

›Emergent surgical aortic valve replacement

›Do not delay

›Class I recommendation

›Operating room activation

›Cardiac anesthesia and perfusion

›Cross-match blood products

›Pharmacologic bridge

›Nitroprusside infusion

›Start 0.3 mcg/kg/min IV

›Titrate by 0.5 mcg/kg/min every 5 minutes to afterload reduction

›Maximum 10 mcg/kg/min and limit duration for cyanide risk

›Inotropic support if hypotensive

›Dobutamine 2 to 20 mcg/kg/min IV

›Dopamine alternative to augment forward flow

›Heart rate management

›Preserve compensatory tachycardia

›Avoid agents that slow rate in isolated acute AR

›Contraindicated interventions

›Intra-aortic balloon pump

›Augments diastolic pressure

›Worsens regurgitation

›Pure vasoconstrictors

›Phenylephrine and vasopressin increase afterload

›Worsen AR

›Beta-blockers in isolated acute AR

›Block protective tachycardia

09Special Populations/sp42

Pregnancy

›Hemodynamic considerations

›Physiologic adaptation often tolerated

›Decreased systemic vascular resistance reduces regurgitation

›Tachycardia of pregnancy is protective

›Decompensation risk

›Severe symptomatic AR before pregnancy

›Pre-conception counseling and repair

›Management adjustments

›Medication safety

›ACE inhibitors and ARBs contraindicated

›Hydralazine and nifedipine for afterload and BP control

›Delivery planning

›Multidisciplinary cardio-obstetric team

›Avoid prolonged Valsalva in severe AR

Geriatric

›Etiology and presentation

›Common causes

›Age-related calcific degeneration

›Aortic root dilation and hypertension

›Atypical presentation

›Fatigue and reduced exertion masking symptoms

›Comorbidity overlap

›Management adjustments

›Surgical risk assessment

›Frailty and comorbidity weighting

›Consider prohibitive-risk GDMT pathway

›Medication considerations

10Background/b44

Epidemiology

›Disease burden and causes

›Etiologic distribution

›Bicuspid aortic valve leading congenital cause in high-income countries

›Rheumatic disease leading cause in low- to middle-income countries

›Secondary AR

›Chronic hypertension and root dilation

›Functional aortic regurgitation

›Prognosis

›Mortality with LV dysfunction

›Annual mortality exceeds 20% when LVEF < 30%

›Decreasing diastolic BP independent mortality risk

›Mixed disease frequency

›~20% of severe AR have concomitant aortic stenosis

Pathophysiology

›Mechanism of regurgitation

›Primary valve pathology

›Intrinsic leaflet disease

›Endocarditis or rheumatic destruction

›Secondary root pathology

›Annular and aortic root dilation

›Incomplete leaflet coaptation

›Hemodynamic progression

›Chronic compensation

›Eccentric LV hypertrophy and dilation

›Maintained stroke volume for years

›Decompensation

›Maladaptive remodeling and myocardial fibrosis

11Patient Discharge Instructions/pdi19

copy discharge instructions

›Aortic regurgitation home care

›Take all heart and blood pressure medicines exactly as prescribed

›Keep all cardiology and echocardiogram follow-up appointments

›Weigh yourself daily and report rapid weight gain

›Limit salt in your diet

›Activity guidance

›Mild to moderate leak: usually no activity restriction

›Severe leak: avoid heavy weightlifting and competitive sports

›Resume activity gradually after any procedure

›Warning signs to return to ER

›New or worsening shortness of breath, especially at rest or lying flat

›Chest pain or fainting

›Sudden severe shortness of breath

›Fever with a new or changing heart murmur

›Sudden tearing chest or back pain

›Follow up

›Cardiology follow-up as scheduled

›Repeat echocardiogram on the recommended interval

›Dental hygiene and tell providers about your valve condition

12References/r15

Guidelines and key sources

›Valvular heart disease guidelines

›2020 ACC/AHA Guideline for Management of Valvular Heart Disease

›2014 AHA/ACC Valvular Heart Disease Guideline

›ESC/EACTS valvular heart disease guidelines and 2025 thresholds

›Aortic disease and acute care sources

›2022 ACC/AHA Guideline for Diagnosis and Management of Aortic Disease

›Acute Decompensated Valvular Disease in the Intensive Care Unit (JACC Advances 2024)

›State-of-the-art reviews

›Contemporary Diagnosis and Treatment of Aortic Regurgitation (JACC 2026)

›Imaging Methods for Evaluation of Chronic Aortic Regurgitation (JACC 2023)

›Valvular Heart Disease From Mechanisms to Management (Lancet 2024)

›Coding standards

›ICD-10 I35.1 aortic insufficiency

›ICD-10 I06.1 rheumatic aortic insufficiency

›SNOMED CT aortic valve regurgitation disorder concept

Evidence & Review

Evidence & Review