Aortic regurgitation in aortic dissection

A diastolic murmur can change the diagnosis

Patient arrives with chest pain in the emergency room, instinctively you ask for an ECG that shows an elevation. The first diagnosis that comes to your head is AMI STEMI, but you decide to examine the patient’s precordium and auscultate an aspiration diastolic murmur in an aortic focus. Does a new possibility appear in your list of diagnostic hypotheses?

Since the advent of TAVR, the left ventricular outflow tract has received special attention and it has become standard to call this region an aortic complex. In cases of type A aortic dissection (involvement proximal to the aortic arch with or without distal involvement), components of the aortic complex may be involved and, as a result, we may have aortic valve dysfunction with the appearance of regurgitation. Given this scenario, many may ask what is the best course of action besides correction of the dissection, valve repair or replacement with prosthesis?

For this, the involvement of the valve was divided into 3 types:

`Type 1: normal mobility of the leaflets – etiology is the dilation of the sinotubular junction (1a), sinus of Valsalva (1b) or annulus (1c);

Type 2: excessive mobility of the leaflets;

Type 3: restricted mobility of the leaflets.

Type 1a is surgically corrected with repair of the ascending aorta, which in itself reduces dilation and causes the leaflets to coaptate normally again. Subtype b can be resolved in the same way or may require valve replacement depending on how much the aortic annulus was affected and the surgeon’s experience. Types 1c and d are rarely seen in cases of acute dissection, because upon reaching the annulus, the dissection is directed to the pericardium, avoiding affecting both this structure and the leaflets. In these cases, it is also necessary to understand the degree of involvement of the coronary ostia that will increase the morbidity and mortality of the event as a whole.

Type 2 occurs due to leaflet deployment detachment, which may be symmetrical or not. Treatment includes valve repair with resuspension and redeployment of the leaflets at the level of the sinotubular junction. In more dramatic cases with advanced destruction of the aortic root, valve replacement with a prosthesis combined with the aortic tube (Bentall and De Bono) may be necessary.

Type 3 occurs when an intimal fragment prolapses and restricts the mobility of one or more leaflets. In these cases, the same intimal fragment can occlude a coronary ostium making the picture more dramatic. The surgical treatment of valvopathy consists of removing the flap to restore the valve’s functionality.

Thus, the decision to preserve or not the native valve involves anatomical issues, the surgeon’s ability and the risk/benefit of the procedure, which alone adds high mortality.

Suggested literature:

1 – Patel PA, Bavaria JE, Ghadimi K, et al. Aortic Regurgitation in Acute Type-A Aortic Dissection: A Clinical Classification for the Perioperative Echocardiographer in the Era of the Functional Aortic Annulus. J Cardiothorac Vasc Anesth. 2018 Feb;32(1):586-597.

 

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