Aortic Regurgitation

Question 1

What are the aortic valve leaflets causes of AR?

Answer 1

1. Rheumatic heart disease
   - Commonest in developing world
2. Congenital bicuspid
3. Degenerative (calcification)
4. Endocarditis

Question 2

What are the aortic root causes of AR?

Answer 2

1. Connective tissue disorder
   - Marfan’s
   - Ehlers-Danlos syndrome
2. Aortitis
   - Inflammation of the aortic root
   - Associated with RA, AS, GCA, SLE
3. Aortic dissection

Question 3

What is pathophysiology of the acute causes of AR?

Answer 3

Firstly.. acute causes are endocarditis, dissection and rheumatic fever

• It is a medical emergency as valvular incompetence occurs rapidly and compensatory changes seen in chronic disease cannot develop
  1. Regurgitation of blood during diastole causes an increase in the LVEDV
  2. This leads to reduced coronary flow during diastole, leading to angina/myocardial ischaemia
  3. Increased LVEDV leads to pulmonary oedema, dyspnoea and cardiogenic shock as CO drops dramatically

Question 4

What is the pathophysiology of chronic aortic regurgitation?

Answer 4

1. Increased LVEDV, aka the preload
2. This leads to LV dilatation and eccentric hypertrophy, this maintains the ejection fraction as a greater preload leads to greater contractility
3. Leads to left sided heart failure eventually as preload increases

Question 5

What are the acute symptoms of AR?

Answer 5

Sudden dyspnoea
Chest pain
Bi-basal crackles
Raised JVP

Question 6

What are the chronic symptoms of AR?

Answer 6

Heart failure symptoms
- PND, orthopnoea, dyspnoea, syncope
Increased SV -
- Palpitations
Other - 
- Angina

Question 7

What are the signs of AR, other than a murmur?

Answer 7

• Collapsing (water hammer) pulse
• Wide pulse pressure (>60)
• Displaced, hyperdynamic apex beat
• Quincke’s sign (capillary pulsation in nail beds)
• De Musset’s sign (head nodding with each beat)
• Muller’s sign (vibrating uvula)
• Traube’s sign (pistol shot femoral pulses)

Question 8

What murmur is heard in AR?

Answer 8

Early decrescendo diastolic murmur

Question 9

What investigations would you undertake in suspected AR?

Answer 9

Bedside -

• Observations
• BP
• ECG (showing signs of LVH)

Bloods -

• FBC
• U+E
• Cholesterol
• Clotting

Imaging -

• Echocardiogram (diagnostic)
• CXR
• MRI - if echo is ambiguous
• CT - Characterize dilatation and max diameter
• Angiography preoperatively to assess coronary artery disease and severity of lesion, anatomy of root etc

Question 10

What would a CXR show?

Answer 10

Signs of left sided heart failure - 
- Cardiomegaly
- Pulmonary oedema
Pathology - 
- Dilated ascending aorta

Question 11

What is the management for acute AR?

Answer 11

Surgical emergency!!!
Aortic dissection - Emergency open surgery, root replacement and valve repair/replacement
Infective endocarditis - Coronary angiogram if stable, replace the valve

Question 12

What is the management for chronic AR?

Answer 12

Medical -

• Anti hypertensives for systolic hypertension
• Echo every 6-12 months to monitor

Surgical -

• Valve replacement
• Indicated if ascending aorta enlarge, symptomatic, LVEF <50%, Marfan’s with large diameter