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Apr 1, 2012

Combined lesion Aortic Stenosis (AS) and Aortic Regurgitation (AR)


Combination of AS with AR is common, about two third of calcific AS have AR due immobile calcified valve. Development of infective endocarditis in AS may cause AR. Rheumatic aortic valve disease leads more often predominant AR with mild to moderate AS
Mild gradient across aortic valve is present in AR without AS.
AR leads to volume overload and AS pressure overload. AR cause Hyperdynamic circulation and AS causes low cardiac output. In AR stroke volume is more, but due to AS this stroke volume is reduced in combination lesion. More often clinical features of AR are reduced in presence of AS.
Physical findings
Ejection systolic murmur (ESM) and early diastolic murmur (EDM) together presence suggest combined lesion.
ESM can be present in AR without AS may even be associated with thrill. AS Differentiating features are, slow carotid up stoke with anacrotic notch, murmur of AS is harsher and peaks later, Paradoxical splitting or single S1.
Very often in presence of severe AS with harsh ESM, EDM of AR may be missed. To bring out EDM, handgrip exercise, squatting should b tried. Some times Austin flint murmur is only a sign of AR.
S4 can be present in both AS and AR, but S3 is in AS with regurgitant lesion either MR or AR, or is only present in presence of heart failure
Presence of widened pulse pressure with brisk carotid pulse suggest predominant AR than AS
Carotid shudder can be present in both AS and AR
Apical impulse in AS can be heaving with palpable S4.
Apical impulse is displaced latterly and inferiorly or associated with early diastolic shock suggest regurgitant lesion, either MR or AR
ECG
Volume overload of AR pattern with septal q waves in V5 and V6 with ST and T waves deflection towards same side of QRS.
ST and T wave deflection opposite to QRS i.e. systolic or pressure overload is present in AS and also in later stages of AR
Left atrial enlargement is seen in both
In younger patient with predominant AR, signs of LVH by voltage criteria are present with volume overload  so not reliable sign of associated AS.
Chest X ray
In combined lesions of AS and AR,  LV is enlarged,  more than isolated AS.
Aortic valve calcification may be seen more often with combined lesion than with AS alone.
In isolated AR, valve calcification is unusual.
Dilatation of proximal aorta is common to both lesion.
Echocardiography
Doppler gradient across the aortic valve may apparently increase in presence of AR. So AS severity by pressure gradient may be overestimated. For this aortic valve area calculation by 2D planimetry (if LV function is normal) or continuity equation is used
Cardiac catheterization
Aortic valve area by Gorlin formula underestimates valve area with more than mild AR
Severity AR in cath lab is best estimated by supra valvular aortogram.
 Therapy
Rotman et al series shows long term results following aortic valve replacement are better in combined lesion than in isolated AS. Possible explanation significant volume overload leads to early symptoms with preserved LV function.

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