Clinical and echocardiographic predictors of decompensation in acute severe aortic regurgitation due to infective endocarditis

Abstract

Background: Patients with acute severe aortic regurgitation (AR) due to infective endocarditis can progress rapidly from the hemodynamically stable patient to pulmonary edema and cardiogenic shock. We sought to identify patients at risk of decompensation where emergent surgery should be undertaken. Methods:We identified 90 patients with acute severe AR from the echocardiography laboratory database. Baseline clinical, hemodynamic (heart rate (HR) and blood pressure (BP)), and echocardiographic data including mitral filling, premature mitral valve closure (PMVC), and diastolic mitral regurgitation (DMR) were identified. The primary endpoint was subsequent development of pulmonary edema or severe hemodynamic instability.Results: Patients who met the primary endpoint had a higher HR (98.5 bpm vs 80.5 bpm), lower diastolic BP (54 mm Hg vs 61.5 mm Hg), higher mitral E-wave velocity (113 cm/s vs 83 cm/s), higher E/e′ ratio (12.4 vs 8), higher proportion of DMR (27.8% vs 7.4%), and PMVC (25% vs 9.3%) than patients who did not meet the endpoint. The proportion of patients with the primary endpoint increased as HR increased ((≤81 bpm) 3/30 (10%), (81-94 bpm) 11/31 (35.5%), (≥94 bpm) 22/29 (75.9%), P < .0001) and as the diastolic BP reduced ((≤54 mm Hg) 19/31 (61.3%), (54-63 mm Hg) 12/31 (38.7%), (≥63 mm Hg) 5/28 (17.9%), P = .003). Independent predictors were a higher HR (OR 1.08 (95% CI 1.04-1.13) P = .0003) and DMR (OR 4.71 (95% CI 1.23-18.09), P = .02). Conclusion:Decompensation in acute severe AR is common. Independent predictors of decompensation are increasing HR(≥94 bpm) and the presence of DMR. Those with these adverse markers should be considered for emergent surgery.

Echocardiographic assessment of aortic regurgitation: a narrative review

“…Therefore, their presence suggests urgent surgical intervention [ 52 , 53 ]. In addition, the presence of diastolic mitral regurgitation is an independent predictor of pulmonary oedema and/or haemodynamic instability in patients with acute severe AR and therefore is another echocardiographic finding that may play an important role in patient’s management plan and prognosis [ 54 ].…”

Acute native aortic regurgitation: clinical presentation, diagnosis and management

“…Surgical intervention is the only definitive therapy for acute regurgitation of a native aortic valve, although palliative care can be considered depending on the clinical situation and comorbid conditions. Medical stabilisation prior to intervention is challenging and a major goal should be to minimise the time to definitive therapy 32. Haemodynamic monitoring in the intensive care unit is recommended with careful titration of inotropic agents and vasodilators to augment cardiac output, support end-organ perfusion and reduce LVEDP 33.…”

Acute native aortic regurgitation

“…The most important causes of this situation are acute aortic dissection 2 and sudden structural defects in the heart valves due to infective conditions. 3 The cause of AAR in aortic dissections is the loss of commissural support of the valves. However, more rarely, circumferential intimal flap prolapsing to the left ventricular outflow tract causing AAR has been reported.…”