Aortic Regurgitation

Question 1

If both AS and AR is present what is the likely predominant lesions

Answer 1

AS

Question 2

Acute causes of AR

Answer 2

IE
Prosthetic valve failure
Aortic dissections
ruptured sinus of Valsalva
acute rhematic fever

Question 3

Chronic cause of AR

Answer 3

Bicuspid AV
IE
Ankylosing spondylitis
Marfans syndrome
dilated aortic root
syphilis
Rheumatic heart disease

Question 4

How might AR present

Answer 4

SOB
Pulmonary oedema
Cardiac failure
back pain (dissection)
Fever (IE)
PND
noctural angina

Question 5

Clinical signs of AR not on auscultation

Answer 5

Collapsing pulse
Wide pulse pressure
Displaced laterally thrusting (volume overload) apex beat

Question 6

Eponymous signs of AR

Answer 6

Corrigan’s - dancing carotid
Quinkes - Nail bed pulsations
De Mussets - head bobbing
Mullers - uvula pulsations
Traubes - pistol shot over femoral art.

Question 7

Sign on auscultation of AR?

Answer 7

Early diastolic murmur heard leaning forward on expiration
may have aortic flow murmur
Austin flint murmur

Question 8

Does the degree of murmur indicate severity in AR?

Answer 8

No, actually the shorter the murmur the more severe. This is due to rapid equalisation of pressure of the AV with more severe regurgitation

Question 9

why may an aortic flow murmur be present in AR?

Answer 9

Increased EDV within the LV due to regurgitant flow
this is then forced through the AV in systole

Question 10

What is an Austin Flint murmur

Answer 10

Mid-diastolic murmur heard due to regurgitant flow impeding the opening of the anterior cusp of the mitral valve.

Question 11

Causes of collapsing pulse

Answer 11

AR
High output states (fever/ pregnancy/ anaemia)
PDA
Pagets

Question 12

Differentials of AR

Answer 12

Pulmonary regurgitation

Question 13

What are the causes of dilated aortic root

Answer 13

Marfans syndrome
Syphilis
Bicuspid AV
Ank Spond
HTN
EDS

Question 14

What are the investigations of AR?

Answer 14

ECG
Echocardiogram
coronary angiogram
cardiac MRI

If thinking IE 3x BCs

Question 15

What is the medical management of AR?

Answer 15

ACEIs
Diuretics

Typically reserved for chronic asymptomatic AR

Question 16

What is the surgical option for management of AR?

Answer 16

Aortic valve replacement

Question 17

What are the indications for surgical management of AR

Answer 17

DEADS

Dilated LV >55cm
EF <50%
Any other cardiac surgery
Dilated aortic root (>55cm) (Marfans >45cm, Bicuspid >50cm)
Symptomatic

Question 18

Complication of AR

Answer 18

Heart failure
endocarditis

Question 19

How is severity graded in AR clinically?

Answer 19

Heart failure
Cardiomegaly
Wide pulse pressure
Short murmur

Question 20

Present a case of typical AR

Answer 20

Today I examined Mr Smith. On examination MR Smith has a collapsing pulse, displaced lateral apex beat and a early diastolic murmur heard loudest on expiration. These findings would be most consistent with aortic regurgitation. I did not observe any eponymous signs in this examination but would want to check for nail bed pulsations and uveal pulsation. There was/was not any peripheral stigmata of endocarditis such as splinter haemorrhages or janeway lesions. There was/ was not evidence of cardiac decomposition in that there was no peripheral oedema, raised JVP or pulmonary oedema.

Therefore, to summaries. This patient has sign of aortic regurgitation. I suspect in this patient the underlying cause my be XXX. Differential diagnosis include XXX

Question 21

Other than AR how else might marfans effect the CVS

Answer 21

Aortic dissection
MV prolapse
Dilated aoritc root
mitral annular calcification

Question 22

Genetics of marfans syndrome

Answer 22

Autosomal dominant
mutation in fibrillin 1 gene on chromosome 15