Acute valvular

regurgitation
Prosthesis malfunction
ACUTE MITRAL INSUFFICIENCY
e mitral insufficiency-
insufficiency- etiology
Patients with AMI are often unstable and require immediate intervent

Papillary or mitral cusps rupture in the context of

endocarditis, ischemia, mixomatous cusps,
traumatism or spontaneous rupture

AMI in the context of ARF

AMI due to prosthesis malfunction

AMI due to papillary necrosis

e mitral insufficiency-
insufficiency- etiology
emodynamic changes more severe than in chronic MI
epend on the severity
LA and LV does not
comply to the high
volume

Neurumoral activation due to CO Increase of

Decrease in CO
decrease-increases vascular pressure in the LA

resistance and accentuates MI

f MI is limited, AS compliance
ncreases while pulmonary
capillary pressure decreases and
hemodynamics improves
APE Cardiogenic shock
e mitral insufficiency-
insufficiency- Clinics

Cardiac emergency
Severe dyspnoea, PE, hipoBP, cardiogenic shock signs
Severe PHT can lead to heart failure
If the acute MI overlaps with a chronic IM, the symptom may be
minimal, in this case not being addressed in the emergency system
Patients may experience increased dyspnoea, fatigue.
e mitral insufficiency-
insufficiency- Clinics

Signs of PE (tachycardia, pallor, sweat, agitation)

Pulse is fast and poorly represented due to low DC
Jugular Turgescence (Right HF)
Hyperdinamic apical impulse
Harzer Sign (RVH)
Listening: Proto-holo or mid-systolic murmur
audible parasternal left and at the base of the heart
S3 audible in heart failure
In the presence of PHT, murmurs of tricuspid or pulmonary insufficiency can be
appreciated
Approximately 30% of patients with moderate-severe MI have no murmur
e mitral insufficiency-
insufficiency- Investigations

ECG: no specific anomalies

but suggestive changes for
etiology (eg STEMI signs)
RX: Usually, a normal
silhouette cord and signs of
pulmonary congestion (EPA)
 Echocardiography: diagnoses and grade the severity of MI
Bi- three-dimensional - VM flare, cordate rupture, vegetation
- LA dilated
- Normal LV, low CO function
Doppler - view of RM jet (qualitative assessment)
- quantification (PISA method)

egurgitant volume (VR)

egurgitation fraction (RF)
he area of the regurgitant orifice (ERO)
icienta mitrala acuta – Explorări paraclinice
ac catheterization may be indicated prior to surgery
e mitral regurgitation – Tr
Treatme
eatment
nt

Hemodynamic stabilization:
Sodium nitroprusside reduces vascular resistance
Counter-pulse balloon
Surgery:
mortality about 50%
Recommended for patients with severe symptomatic MD
Depends on etiology (preferred plaster)
Percutaneous correction:
in high-risk patients
ACUTE AORTIC INSUFFICIENCY
e aortic insufficiency - etiology
Acute severe aortic regurgitation is usually a medical emergency because of the inability
left ventricle to rapidly adapt to the rapid increase in the volume of the teledostolic fluid
sed by the regurgitant blood

Endocarditis (perforation of the cavity, abscess

aortic ring)

Aortic Dissection (lack of cusps coaptation, flail, prolapse)

Trauma (deceleration / chest injury)

Iatrogenic ( particularly after TAVI)

e aortic insufficiency - physiopathology
n Chronic AI, the LV gradually expands, the ED pressure being maintained normally
n acute AI LV does not adapt LV does not adapt to
the volume overload
tahicardie

Increases the
Low CO
pressure in the LV

Effects are more pronounced in

patients with low hypertrophic LV

Increases pressure Cardio shock,

in the LA hipoBP

PE
e aortic insufficiency - clinics

Cardiac emergency
Severe dyspnoea, EPA, hipoBP, cardiogenic shock signs
Precordial pain with back irradiation, syncope, neurological signs in
aortic dissection
e aortic insufficiency - clinics

Signs of APE (tachycardia, pallor, sweat, agitation)

Pulse slow, fast
Normal or increased systolic BP
Low diastolic BP
Difference of BP arms / lower limbs in Ao dissection
Apical normal impulse
Auscultation: low frequency murmur, proto-diastolic (may lack)
s1 diminished
s2 diminished, P2 enhanced component (PHT)
s3 audible in heart failure
Systolic murmur because of the increased volume of the aortic
valve (sometimes)
e aortic insufficiency-
insufficiency- investigations

ECG:
• There are no specific electrocardiographic changes.
• Non-specific abnormalities of ST and T are common due to high left
ventricular pressure.
• If IA is acute due to aortic dissection, RCA involvement may result in inferior
STEMI appearance
RX:
• the size of the heart is generally normal
• there may be a slight increase in LV silhouette.
• Signs of APE
e aortic insufficiency-
insufficiency- investigations

Echocardiography: diagnoses and grades the severity of AI

• Bi- three-dimensional - valve morphology
• VM flame, cordate rupture, vegetation
• Normal VS function, low DC
• Ao Dissection
• Doppler -
• RM jet visualization (qualitative assessment)
• quantification (PISA method)
Regurgitant volume (VR)
Regurgitation fraction (RF)
The area of the regurgitant orifice
ERO
icienta aortică acuta – Explorări paraclinice
icienta aortică acuta – Explorări paraclinice

TOE echo: is recommended for the diagnosis of AI, gradin the severity
and when TTE echo image is sub-optimal

CT, RMN: gives information on the morphology of the valve, the

etiology, the severity of the AI
e aortic insufficiency - treatment

Hemodynamic stabilization:
• Sodium nitroprusside reduces vascular resistance
• Positive inotropic agents - dobutamine
• In the case of aortic dissection, adm. BB, vasodilators (BPs - 100 mmHg, AV
less than 60 bpm)
Antibiotic therapy in case of infectious endocarditis
Surgery:
• is the only treatment method for acute acute IA
thesis dysfunction

• Obstruction of the prosthesis

• Regurgitation
• Dehiscence
uncția de proteză
Obstruction of the prosthesis
Can be discovered incidentally
Patients have dyspnea, HF, cardiogenic shock, heart rate changes
Etiology: thrombus (most frequently), vegetation, panus (fibroelastic
degeneration, 11-12%),
uncția de proteză
Obstruction of the prosthesis
Diagnosis: ETT, ETE, CT, RM
• Thrombi are hypoecogenic, hyperecogenic panic, mobility of the cusps
• DD etiology (thromb vs panus versus vegetation)
• DD of obstruction: with patient-prosthesis mismatch, dynamic obstruction
Obstrucția de proteză
atment of thrombosis
Prosthesis obstruction
atment:
Panus: recommendations similar to that for native valve lesions
Endocarditis: recommendations similar to that for native valve lesions
thesis dysfunction
Regurgitation
• Valvular / paravalvular
• Paravalvular 17-48 % , regardless the type of prosthesis
thesis dysfunction
Regurgitation
• Normo-functional prostheses have a slight regurgitation degree
• Etiology: Degenerative calcifications, thrombus, panus
• Diagnosis: new murmur, HF signs
• ETT, ETE, CT, RM
Intra-para-prosthetic regurgitation
• Treatment:
• ICC cls III IV NYHA - surgical intervention of reprotection
• Recommendations similar to insufficiency on native valves
Prosthesis dehiscence