Valvular Heart Disease: Regurgitant Lesions

Abstract

• 1. Aortic regurgitation is a flow from the aorta into the left ventricle during diastole leading to both volume and pressure overload.

• 2. Severity is characterized by regurgitant jet size and left ventricular dilatation measured with echocardiography.

Please see Chapter 31: Introduction to Valvular Heart Disease for additional information

Aortic Regurgitation

Definition

• 1. Aortic regurgitation is a flow from the aorta into the left ventricle during diastole leading to both volume and pressure overload.

• 2. Severity is characterized by regurgitant jet size and left ventricular dilatation measured with echocardiography.

Symptoms

Aortic regurgitation can cause dyspnea, angina, and/or palpitations related to tachycardia or arrhythmia.

Incidence

• 1. Chronic aortic regurgitation may be secondary to congenital bicuspid valve, dilated aortic root, rheumatic disease, or other causes such as Marfan syndrome and Ehlers-Danlos syndrome.

• 2. Acute aortic regurgitation may be secondary to endocarditis or aortic dissection.

Interaction with Pregnancy

• 1. Chronic aortic regurgitation is generally well tolerated in pregnancy because decreased systemic vascular resistance, together with increased heart rate which shortens diastolic time, decreases regurgitation [1].

• 2. Acute aortic regurgitation is more likely to cause cardiac complications and require urgent surgical intervention during pregnancy.

Management

• 1. Neuraxial techniques including epidural or low-dose combined spinal epidural or general anesthesia may be used for patients with aortic regurgitation.

  • (a) Slow, small titrations are appropriate especially in patients with aortic regurgitation and left ventricular systolic or diastolic dysfunction.

• 2. Early analgesia may avoid increases in systemic vascular resistance and regurgitation secondary to labor pain.

• 3. A normal to high heart rate minimizes regurgitation time.

• 4. High systemic vascular resistance may increase regurgitation and should be avoided unless regurgitation is accompanied by aortic stenosis.

• 5. Intra-aortic balloon pump is contraindicated in patients with aortic regurgitation.

• 6. Postpartum diuresis and afterload reduction may help avoid volume overload.

Mitral Regurgitation

Definition

• 1. Mitral regurgitation is a flow from the left ventricle into the left atrium during systole.

• 2. Severity is characterized by regurgitant jet size, systolic reversal of flow in the pulmonary veins, and leaflet appearance on echocardiography.

Symptoms

• 1. Mitral regurgitation may cause dyspnea, tachycardia, and/or palpitations.

Incidence

• 1. Mitral valve insufficiency is present in up to 28% of pregnancies [2].

Interaction with Pregnancy

• 1. Mild to moderate mitral regurgitation is generally well tolerated during pregnancy.

Management

• 1. Valve repair or replacement before pregnancy is appropriate for symptomatic women with severe mitral regurgitation.

• 2. Valve repair before pregnancy may be considered in asymptomatic patients with severe mitral regurgitation after discussion about the risks and benefits of the operation and its outcome on future pregnancies [3].

• 3. Neuraxial analgesia/anesthesia and general anesthesia can be used in patients with mitral regurgitation.

• 4. A normal to high heart rate minimizes regurgitation time.

• 5. Preload-dependent lesions, including mitral regurgitation, may be sensitive to preload decreases from neuraxial analgesia/anesthesia. As they are also sensitive to preload increases, volume overload should be avoided.

• 6. High systemic vascular res istance may increase regurgitation and should be avoided unless regurgitation is accompanied by aortic stenosis.

• 7. Postpartum diuresis and after load reduction may help avoid volume overload.

Pulmonic or Tricuspid Regurgitation

Definition

• 1. Pulmonic and tricuspid regurgitation severities are characterized by regurgitant jet size and size of the right ventricle, right atrium, IVC, and hepatic vein on echocardiography.

Symptoms

• 1. Patients with severe disease may be at increased risk for complications including right heart failure and arrhythmias.

• 2. Preexisting right ventricular dilatation or dysfunction increases the risk for complications and surgical intervention [4].

Incidence

• 1. Pulmonic or tricuspid valve insufficiency is present in up to 94% of pregnancies [2].

• 2. Asymptomatic pulmonic or tricuspid regurgitation can be caused by the normal physiologic changes of pregnancy.

• 3. Severe disease can be associated with endocarditis or congenital heart disease.

Interaction with Pregnancy

• 1. Pulmonic or tricuspid regurgitation in the absence of other diseases is usually well tolerated in pregnancy .

Management

• 1. Neuraxial analgesia/anesthesia and general anesthesia can be used in patients with pulmonic or tricuspid regurgitation.

• 2. Patients may require treatment with antiarrhythmic and/or diuretic medication to prevent right heart failure.