Aortic Regurgitation

Question 1

Aortic regurgitation results from an incompetent aortic valve causing a regurgitant flow of blood in ….

Answer 1

Aortic regurgitation results from an incompetent aortic valve causing a regurgitant flow of blood in diastole.

Question 2

Aortic regurgitation tends to present between the fourth and sixth decades of life. It affects … three times more commonly than …

Severe disease is seen in < 1% of the population. The most common causes are degenerative disease and congenital bicuspid valve.

Answer 2

Aortic regurgitation tends to present between the fourth and sixth decades of life. It affects males three times more commonly than women. Severe disease is seen in < 1% of the population. The most common causes are degenerative disease and congenital bicuspid valve.

Question 3

The prevalence of aortic regurgitation increases with ….

Answer 3

The prevalence of aortic regurgitation increases with advancing age.

Question 4

Causes of AR can be split into either primary disease of the aortic valve leaflets; or dilation of the aortic root.

Answer 4

Question 5

An autoimmune condition which follows streptococcal (Group A) infection. Inflammation is a result of molecular mimicry.

What is this describing

Answer 5

Rheumatic heart disease - which can lead to aortic regurgitation

Question 6

Rheumatic heart disease - aortic regurgitation

Answer 6

An autoimmune condition which follows streptococcal (Group A) infection. Inflammation is a result of molecular mimicry. In effect, the immune system produces antibodies that confuse foreign- and self-antigens. Rheumatic heart disease results from cardiac inflammation with acute and chronic results.

Commonest cause in the developing world. Although an increasingly uncommon cause of valvular disease. Chronic disease leads to fibrosis and typically a stenotic valve though regurgitant valves may also develop.

Question 7

What constitutes the commonest causes of aortic regurgitation in the developed world?

Answer 7

Congenital (e.g. bicuspid, quadcuspid valve).

Degenerative (e.g. calcification).

Question 8

Inflammation of the endocardium, typically as a result of infection. Results in acute disease. Vegetations may cause flailing of the valve leaflets.

May cause what murmur?

Answer 8

Inflammation of the endocardium, typically as a result of infection. Results in acute disease. Vegetations may cause flailing of the valve leaflets.

Aortic regurgitation

Question 9

Aortic regurgitation may feature in a number of connective tissue disorders. Aortic root diameter should be monitored in these individuals
What syndromes? (2)

Answer 9

Marfan’s syndrome - caused by a defect in the FBN1 gene.

Ehlers-Danlos syndrome - caused by collagen defects.

Question 10

… syndrome - caused by a defect in the FBN1 gene.
Ehlers-Danlos syndrome - caused by collagen defects.

Both may present with aortic regurgitation

Answer 10

Marfan’s syndrome - caused by a defect in the FBN1 gene.

Ehlers-Danlos syndrome - caused by collagen defects.

Question 11

Aortitis refers to inflammation of the aortic root. May be associated with chronic inflammatory conditions such as rheumatoid arthritis (RA) and ankylosing spondylitis (AS). Also, may occur in Takayasu arteritis, or may complicate Giant cell arteritis.

May lead to which murmur?

Answer 11

Aortitis refers to inflammation of the aortic root. May be associated with chronic inflammatory conditions such as rheumatoid arthritis (RA) and ankylosing spondylitis (AS). Also, may occur in Takayasu arteritis, or may complicate Giant cell arteritis.

Aortic regurgitation

Question 12

Aortic dissection - Stanford A dissections may lead to what murmur?

Answer 12

Aortic regurgitation may complicate in Stanford A dissections, secondary to impaired leaflet coaptation or prolapse. Causes acute disease regurgitation and is a medical emergency.

Question 13

Aortic regurgitation may develop acutely or chronically over a period of many years.

Acute causes?
Chronic causes?

Answer 13

Question 14

Acute aortic regurgitation is a medical emergency - an acute rise in left atrial pressure results in … and … shock

Answer 14

Acute aortic regurgitation is a medical emergency - an acute rise in left atrial pressure results in pulmonary oedema & cardiogenic shock

Question 15

Acute aortic regurgitation is a medical emergency - an acute rise in left atrial pressure results in pulmonary oedema & cardiogenic shock. Valvular incompetence occurs rapidly and the compensatory changes seen in chronic disease do not have time to develop. Regurgitation of blood during diastole causes an increase in the left ventricular end-diastolic volume (and pressure).

The effects of this are two-fold:

Answer 15

Reduced coronary flow - the coronaries fill predominantly during diastole, regurgitant flow at this time reduces filling. Results in angina or in severe cases myocardial ischaemia.
Increased end-diastolic pressure - causes increased pulmonary pressures with resulting pulmonary oedema and dyspnoea. In severe cases, cardiogenic shock may occur.

Question 16

In chronic aortic regurgitation, patients may be …

Answer 16

In chronic aortic regurgitation, patients may remain asymptomatic for many decades

Question 17

Acute AR clinical features

Answer 17

Sudden dyspnoea
Chest pain (consider angina, MI or aortic dissection)
Bi-basal crackles
Raised JVP

Question 18

Chronic AR clinical features

Answer 18

Palpitations
Angina
Dyspnoea
Water hammer pulse
Wide pulse pressure
Chest signs:
Displaced apex
Ejection diastolic murmur
Soft S1 and S2

Question 19

Chest signs:
Displaced apex
Ejection diastolic murmur
Soft S1 and S2

Signs of what murmur?

Answer 19

Chronic aortic regurgitation

Question 20

Signs and symptoms of…

Answer 20

Aortic regurgitation

Question 21

Eponymous signs in aortic regurgitation

Answer 21

de Musset’s - head nodding with the heart beat.
Quincke’s - pulsation of nail beds.
Traube’s - pistol shot femorals.
Duroziez’s - to and fro murmur heard when stethoscope compresses femoral vessels.
Müller’s - pulsation of uvula.

Question 22

de Musset’s - head nodding with the heart beat - seen in what murmur?

Answer 22

Aortic regurgitation

Question 23

Eponymous signs of what?

Answer 23

Aortic regurgitation

Question 24

… is the key diagnostic exam in patients with suspected aortic regurgitation.

Answer 24

Echocardiogram is the key diagnostic exam in patients with suspected aortic regurgitation.

Question 25

Bedside tests for AR (suspected)

Answer 25

Observations
Blood pressure
ECG: left ventricular hypertrophy (deep S-waves in V1 and V2, tall R-waves in V5 and V6) in chronic AR

Question 26

Bloods in suspected AR

Answer 26

Bloods

FBC
U&Es
Cholesterol
Clotting

Question 27

Why is ECHO the key diagnosis investigation for AR?

Answer 27

Echocardiogram: transthoracic echocardiography/transoesophageal echocardiography is the key diagnostic investigation. It allows visualisation of the origin of regurgitant jet and its width, detection of aortic valve pathology and compensatory changes (e.g. left ventricular hypertrophy in chronic AR).

Question 28

What is the most common sign in chronic AR on CXR?

Answer 28

CXR: the most common sign in chronic AR is cardiomegaly. Signs of heart failure are seen in acute AR and advanced chronic AR. It may show a dilated ascending aorta in those with aortic root pathology though the sensitivity is poor.

Question 29

Why may CT/MRI be used in AR?

Answer 29

CT/MRI: MRI may be used to estimate the regurgitant fraction if echo results are equivocal. In patients with aortic dilatation, gated multi-slice CT is the imaging of choice to characterise aortic dilatation and the maximum diameter.

Question 30

When is angiography indicated in AR patients?

Answer 30

Angiography: in patients with chronic AR undergoing surgery, pre-operative angiography is indicated. Typically this is in the form of coronary angiography (invasive procedure) to assess for concomitant coronary artery disease that may require bypass.

Question 31

Aortic regurgitation management - what is indicated in severe disease, symptomatic disease or in the presence of significant enlargement of ascending aorta?

Answer 31

Surgical aortic valve replacement or repair is indicated in severe disease, symptomatic disease or in the presence of significant enlargement of ascending aorta.

Question 32

Acute AR is a surgical emergency. Aortic valve replacement or repair should be performed as soon as possible. It primarily occurs secondary to i… … or aortic dissection, both of which carry very high morbidity and mortality:

Answer 32

Acute AR is a surgical emergency. Aortic valve replacement or repair should be performed as soon as possible. It primarily occurs secondary to infective endocarditis or aortic dissection, both of which carry very high morbidity and mortality:

Question 33

… … (Stanford type A): management depends on the patients pre-morbid state and severity of presentation. If not already there, patients are transferred to the local on-call dissection centre. Emergency open surgery is typically required, management depends on the exact pattern of findings but may consist of root replacement and valve repair or replacement.

Answer 33

Aortic dissection (Stanford type A): management depends on the patients pre-morbid state and severity of presentation. If not already there, patients are transferred to the local on-call dissection centre. Emergency open surgery is typically required, management depends on the exact pattern of findings but may consist of root replacement and valve repair or replacement.

Question 34

… …: management depends upon pattern of valvular involvement (multiple valves may be affected) and complications (e.g. annular/aortic abscess, septic emboli). Coronary angiogram may be performed in selected stable patients prior to operative management. AR is generally an indication for early surgery

Answer 34

Infective endocarditis: management depends upon pattern of valvular involvement (multiple valves may be affected) and complications (e.g. annular/aortic abscess, septic emboli). Coronary angiogram may be performed in selected stable patients prior to operative management. AR is generally an indication for early surgery

Question 35

Chronic AR - surgical management indications

Answer 35

Significant enlargement of the ascending aorta or
Symptomatic severe AR or
Severe AR with LVEF ≤ 50% or LVEDD > 70mm or LVESD > 50mm (may be adjusted for body size)
Marfan’s with aortic root disease with a maximal ascending aorta diameter ≥ 50mm

Question 36

The decision of mechanical vs bioprosthetic valve should take into account patient-specific factors and wishes:

Answer 36

Mechanical valve - require long-term anticoagulation, long lifespan reducing the need for a second operation. Suited to younger patients.
Bioprosthetic valve - no need for long-term anticoagulation, limited life span (around 10 years) and a repeat operation is more likely. Suited to older patients.

Question 37

… valve - require long-term anticoagulation, long lifespan reducing the need for a second operation. Suited to younger patients.
… valve - no need for long-term anticoagulation, limited life span (around 10 years) and a repeat operation is more likely. Suited to older patients.

Answer 37

Mechanical valve - require long-term anticoagulation, long lifespan reducing the need for a second operation. Suited to younger patients.
Bioprosthetic valve - no need for long-term anticoagulation, limited life span (around 10 years) and a repeat operation is more likely. Suited to older patients.

Question 38

T… has been used in patients in whom surgery is contra-indicated but its role in the management of AR has not been formally established.

Answer 38

easingly at expert centres aortic valve repairs are being conducted in select patients and use become more common going forward. Transcatheter aortic valve implantation (TAVI) has been used in patients in whom surgery is contra-indicated but its role in the management of AR has not been formally established.

Question 39

In those with ascending aorta … management depends on the anatomical pattern, patients may need root replacement with reimplantation of the coronary vessels either with preservation of the native valve or with replacement or a supracommissural tube graft replacement.

Answer 39

In those with ascending aorta dilatation management depends on the anatomical pattern, patients may need root replacement with reimplantation of the coronary vessels either with preservation of the native valve or with replacement or a supracommissural tube graft replacement.

Question 40

Which of the following pulse characteristics is associated with aortic regurgitation?

A	Pulsus alternans
B	Slow-rising pulse
C	Waterhammer pulse
D	Jerky pulse
E	Thready pulse

Answer 40

Aortic regurgitation is associated with a collapsing ‘waterhammer’ pulse.
Pulsus alternans refers to a variation in pulse quality felt in cardiac failure. A slow-rising pulse is felt in aortic stenosis. A jerky pulse is felt in hypertrophic obstructive cardiomyopathy (HOCM) and a thready pulse in some types of shock.

Question 41

A 32-year-old female is seen in rheumatology clinic with Marfan’s syndrome. Routine clinical examination reveals an early diastolic murmur, loudest at the lower left sternal edge.

What is the most likely diagnosis?

A	Aortic stenosis
B	Pulmonary stenosis
C	Atrial septal defect
D	Aortic regurgitation
E	Mitral regurgitation

Answer 41

Aortic regurgitation

Marfan’s is an autosomal dominant inherited disorder of connective tissue that can lead to aortic root dilatation and subsequent aortic regurgitation.

Question 42

What is Marfan syndrome?

Answer 42

Marfan’s is a multi-system disorder due to a mutation in the fibrillin 1 gene that is important in connective tissue. In the vasculature, abnormal connective tissue leads to aortic root dilatation and subsequent aortic regurgitation that causes an early diastolic murmur, heard loudest at the lower left sternal edge. These patients are also at risk of aortic dissection. Other cardiac abnormalities include mitral valve prolapse that causes a mid-systolic click with later systolic crescendo-decrescendo murmur. This murmur is loudest in the mitral area/sternal edge and there is typically no radiation to the axillae.

Question 43

… is an autosomal dominant inherited disorder of connective tissue that can lead to aortic root dilatation and subsequent aortic regurgitation.

Answer 43

Marfan’s is an autosomal dominant inherited disorder of connective tissue that can lead to aortic root dilatation and subsequent aortic regurgitation.