Aortic Regurgitation

Question 1

what is the definition of aortic regurgitation?

Answer 1

Leakage of blood into the left ventricle from aorta during diastole due to ineffective coaptation (bringing together) of the aortic cusps, of which there are three

Question 2

what is the epidemiology of aortic regurgitation?

Answer 2

The incidence of clinically significant aortic regurgitation (AR) increases with age, typically peaking in the fourth to sixth decade of life. It is more common in men than women.

Question 3

what is the aetiology of aortic regurgitation?

Answer 3

• Main causes:
  • Congenital bicuspid aortic valve (BAV) - chronic
  • Rheumatic fever - chronic
  • Infective endocarditis - acute

Question 4

what are the risk factors for aortic regurgitation?

Answer 4

• SLE
• Marfan’s and Ehlers-Danlos syndrome - connective tissue disorders
• Aortic dilatation
• Infective endocarditis of aortic dissection

Question 5

what is the pathophysiology for aortic regurgitation?

Answer 5

• Aortic regurgitation is reflux of blood from the aorta through the aortic valve into the left ventricle during diastole
• If net cardiac output is to be maintained, the total volume of blood pumped into the aorta must increase and, consequently, the left ventricular size must enlarge resulting in left ventricle dilation and hypertrophy
• Progressive dilation leads to heart failure
• Furthermore due to the fact that the remaining blood in the root of the aorta supplies the coronary arteries via the coronary sinus during diastole - regurgitation causes diastolic blood pressure to fall and thus coronary perfusion decreases
• Also the large left ventricular size is mechanically less efficient, so that the demand for oxygen is greater and cardiac ischaemia develops

Question 6

what are the key presentations for aortic regurgitation?

Answer 6

• In chronic regurgitation, patients remain asymptomatic for many years before symptoms develop
• breathlessness on exertion, palpitations angina, wide pulse pressure
  presence of risk factors
  diastolic murmur

Question 7

what are the signs of aortic regurgitation?

Answer 7

Wide pulse pressure
- Apex beat is displaced laterally
- Heart sounds:
• Diastolic blowing murmur at the left sternal border
- Collapsing water hammer pulse (bounding and forceful rapidly increasing and subsequently collapsing)
- Quincke’s sign - capillary pulsation in the nail beds
- de Musset’s sign - head nodding with each heartbeat
- Pistol shot femoral - a sharp bang heard on auscultation

Question 8

what the the symptoms of aortic regurgitation?

Answer 8

Asymptomatic till the 4th or 5th decade

• Exertional dyspnea
• Palpitations
• Angina
• Syncope
• orthopnoea

Question 9

what are the first line and gold standard investigations for aortic regurgitation?

Answer 9

ECG:
• Signs of left ventricular hypertrophy due to ‘volume overload’ - tall R waves and deeply inverted T waves in the left-sided chest leads, and deep S waves in the right-sided leads
CXR:
• Enlarged cardiac silhouette and aortic root enlargement
• Left ventricular enlargement
Echocardiogram:
• Evaluation of the aortic valve and aortic root
• Measurement of left ventricle dimensions and function
• Cornerstone for decision making and follow up evaluation
M-mode and 2D imaging -assessment of valvular anatomy, aortic root dilation, and left ventricular response to volume overload
colour flow doppler
pulse wave doppler
continuous wave doppler

Question 10

what are the differential diagnoses for aortic regurgitation?

Answer 10

• Heart failure
• Infective endocarditis
• Mitral regurgitation

Question 11

how is aortic regurgitation managed?

Answer 11

• In general consider infective endocarditis prophylaxis
• Vasodilators such as ACE-inhibitors such as Ramipril will improve stroke volume and reduce regurgitation but only if patient is symptomatic or has hypertension
• Serial echocardiograms to monitor progression
• Surgery for valve replacement:
  • If symptoms are increasing, enlarging heart on CXR/ECHO, ECG deterioration (T wave inversion in lateral leads)

Question 12

how is aortic regurgitation monitored?

Answer 12

regular heart monitoring

Question 13

what are the complications of aortic regurgitation?

Answer 13

Fainting or feeling lightheaded
Heart failure
Infections that affect the heart, such as endocarditis
Heart rhythm problems (arrhythmias)
Death

Question 14

what is the prognosis of aortic regurgitation?

Answer 14

Three fourths of patients with significant aortic regurgitation survive 5 years after diagnosis; half survive for 10 years. Patients with mild to moderate regurgitation survive 10 years in 80-95% of the cases.