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Posts Tagged ‘aortic valve repair in ar’

Aortic regurgitation complicating VDS  is an important clinical  entity in congenital heart disease.It is  also  a popular case for the cardiology fellows in their  final clinical examinations . AR is a  late manifestation of VSD (usually in early  adolescent  or adult hood) .This develops due to loss of aortic valvular support provided by the inter ventricular   septum.

In fact ,   IVS can be termed  as a foundation stone  on which  a  part of  aorta (Mainly its anterior part) rests . So, it is not surprising VSD patients  are prone to develop AR especially,  as they grow when aorta tires to outgrow the septal support . Further,  the hemodynamics of VSD has a crucial impact on the AR progression.(See image below)

Pulse /Blood pressure

Large volume pulse,  may be collapsing

Peripheral signs of Aortic run off usually present

Apical impulse

Shifted down and out Hyperdynamic

Murmur

To and fro murmur (To -Systolic , Fro -Diastolic )

It is differentiated from continuous murmur by a distinct reduction  in the intensity of murmur towards the end systole and a different murmur  appear  in diastole  . While , a continuous murmur  is  a single murmur  that peaks  around sound  heart sound , overlaps the second  heart sound and spills well into diastole.

Other useful diagnostic clues

  • Usually the VSD  is  restrictive  .Left to right shunt is often below  2:1
  • With the onset of AR  ,there is  further reduction in the left to right shunt of VSD
  • Hence,progressive pulmonary arterial hypertension is uncommon and Eisenmenger is reaction is very rare in  VSD with AR.
  • Presence of AR makes  LV dilatation disproportionate to VSD  shunt  (LV size  is not useful to assess the  hemodynamic  significance of VSD)
  • LV dilatation invariably means significant AR rather than VSD.  VSD induced LV enlargement  is  usually less conspicuous as it is  represents  physiological flow across mitral  inflow .  While , AR is a high gradient leak  from a non-physiological chamber (Aorta)
  • ECG volume overload of LV   is  evidenced by  more prominent * q waves in  V5 V6

*Double dose of volume overload (AR +VSD)

Management

  • If AR is mild ,only VSD closure is advocated *
  • If AR is moderate  , repair of aortic valve is  considered along with VSD closure.
  • For severe AR , Aortic valve replacement or repair with VSD closure mandatory.
  • Device closure of VSD and percutaneous  aortic valve replacement  not feasible at the moment .May be a future possibility.

* If both  VSD and AR are very small ,  simple follow up , and observation (Leaving the patient happy!)  could be a distinct option !

Pathogenesis of AR in VSD : The landmark article from Japan in 1973 by Tatsuno  and Sakakibara

http://circ.ahajournals.org/cgi/content/short/48/5/1028

Thanks to circulation .Such articles are made available .

http://circ.ahajournals.org/cgi/reprint/48/5/1028

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