Aortic Regurgitation Flashcards
Case presentation script for aortic regurgitation
Think presenting as reversal of examination steps
A. Diagnosis of aortic regurgitation and cause
1. Early diastolic murmur of grade (1-3) over LLSE, accentuated with leaning forward and expiration
2. Apex beat is deviated and thrusting
3. Signs of AR to support diagnosis
4. Severity of AR: wide pulse pressure, long duration of murmur, soft A2, S3 heart sound
5. Any Marfanoid, rheumatoid, back or pupillary features?
B. Any complications of aortic regurgitation
5. Stigmata of infective endocarditis
6. Atrial fibrillation
7. Pulmonary hypertension (left heart failure)
8. Right heart failure
C. Wishlist - blood pressure over UL and LL
What are the signs/examination findings of aortic regurgitation? (6)
* denotes severe
- Inspection
- Look for disproportionate limbs and long fingers
- Look for any joint deformities and back lordosis/khyphosis
- Look for blue sclera or Argyll-Robertson pupils - Bounding, collapsing pulse
- Severe: *Wide pulse pressure - AR signs (refer AR signs card)
- Look for high-arched palate
- *Deviated, thrusting apex beat
- Characteristic Murmur
6A. Manoeuver to lean forward, expiration
- Early diastolic murmur (EDM) over LLSE (valvular) vs RSE (aortic root)
- *Long duration of diastolic murmur
- Listen for any ESM from functional or concomitant AS
- *Austin Flint murmur (functional MDM at apex) - due to regurgitant jet striking MV anterior leaflet, obstructing flow from LA into LV - Supportive heart sounds
- *Soft S2 (A2)
- *Third heart sound (S3) - Signs of complications
- *Pulmonary hypertension
- *Heart failure
What are the characteristic signs in AR?
- Collapsing pulse
- Brachial dance
- Quickne - visible capillary pulsation in nail bed
- Corrigan - visible carotid pulsation in neck
- De Musset - head nodding with heart beat
- Mullet - uvula systolic pulsation
- Duroziez - femoral compression produces to/fro murmurs
- Traube (pistol shot) - booming sound over femoral arteries
- Hill - higher SBP in leg compared to arm
Describe this heart sound
Early diastolic murmur - AR
In aortic regurgitation, apart from EDM over LLSE, there is often accompanied soft ESM over aortic valve.
This can be due to (2): increased forward flow (functional from SV + regurgitant volume) or concomitant aortic stenosis
Differential diagnosis of diastolic murmur? (5)
(copied from MS - differentials of diastolic murmur)
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AR, atrial myxoma, thrombus, severe MR, MS
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- Austin flint murmur (severe AR)
- Left atrial mass (atrial myxoma)
- Left atrial thrombus (ball-valve thrombosis)
- Severe mitral regurgitation (increased flow through mitral valve during diastole)
- Mitral stenosis
- Flow across tricuspid valve in ASD
- Cor triatriatum - congenital defect with 3 atria divided by fibromuscular band
What are the causes of aortic regurgitation? (min 7)
- Acute, chronic (M: AIR CARS C:RARMH)
Congenital (bicuspid), Marfan, rheumatic, aortic dissection, CTD, SoV rupture, syphilis
Acute
Aortic dissection
Infective endocarditis (valvular)
Rupture of sinus of valsalva aneurysm
Chronic
Congenital: bicuspid aortic valve, VSD with aortic cusp prolapse
Rheumatic fever/heart disease (valvular - co-exist AS)
Aortitis
Syphilis (tertiary) (used to be no. 1 cause 200 years ago)
Hypertension
Connective tissues diseases (aortic root dilatation)
- Acquired: RA, AS, Reiter, EDS, OI
- Congenital: Marfan
What is your expected findings on taking BP in AR?
- Wide pulse pressure
- Severe hypertension
- LL > UL SBP discrepancy (Hill’s sign)
How would you investigate a patient with aortic regurgitation?
- ECG (2), CXR (5), TTE, complete workup
ECG
- LVH with diastolic overload (deep narrow Q, ST-d, TWI in left leads)
- LBBB in late disease
CXR
- Calcified valve
- Cardiomegaly
- Widened aorta
- Pulmonary congestion
- Prominent pulmonary arteries
TTE
- Assess valve, establish cause and severity of AR
- Left ventricular size and function
- Complications
Coronary angiography: coronary artery disease
CT or cMRI: assess aortic root and ascending aorta
What are the complications of AR? (2)
- Left heart failure
- Infective endocarditis
- Eventual right heart failure
How would you manage a patient with aortic regurgitation?
- Education
- Antibiotics prophylaxis
- Treat underlying cause
- Treat complications of CCF, IE
- Vasodilators if severe AR and LV dilatation: ACEi, CCB
- Consider for valve replacement *see indication
What are the types of surgery available for AR?
What is the operative mortality rate of AR?
- Transcatheter aortic valve implantation (TAVI) for non-surgical candidates
- Primary surgical repair - only torn/perforated leaflet
- Valve sparing aortic root reconstruction (David procedure)
- Aortic valve replacement
Operative mortality risk
2% isolated AVR
3.6% AVR + coronary artery bypass
What are the indications for aortic valve replacement in AR?
- Symptomatic - CCF, angina, severe AR
- LV dilatation: LV ESD > 55mm or LV EDD > 65mm
- Aortic root dilatation > 55mm
- Resting LVEF < 55%, exercise LVEF reduction >5%
What is the prognosis of AR?
Annually 4% develop symptoms or CCF
Collapsing pulse is also known as water hammer pulse.
- Find the most proximal aspect of palpable radial pulse and place fingers just below.
- Ask patient if there is any shoulder pain
- Lift the arm up, pulse becomes stronger
What are the causes of collapsing pulse?
Cardiac related
1. AR
2. PDA
3. Aortopulmonary window
4. Ruptured aortic sinus aneurysm
5. Severe bradycardia
6. Severe MR
Hyperdynamic circulation
7. Paget’s disease
8. High fever
9. Severe anaemia
10. Pregnancy
11. Thyrotoxicosis
How do you differentiate Austin Flint murmur of AR from MS?
Aortic regurgitant jet impinges on anterior mitral valve leaflet causing functional mitral stenosis.
MS
1. Opening snap
2. Loud S1
3. Tapping apex beat, not displaced
Pathophysiology of AR
Pathophysiology of AR: different in chronic vs acute AR
In chronic AR:
1. Severe AR, volume of regurgitant flow may be equal to effective forward stroke volume, thus poor cardiac output
2. Compensatory LV dilation and eccentric hypertrophy to eject larger stroke volume
3. Eventual compensatory failure - LV function deteriorates causing reduced stroke volume and EF
4. Cardiac ischaemia due to cardiac hypertrophy increasing oxygen requirement and systolic tension, which compromised coronary blood flow
5. Failure of cardiac output to rise during strenous activities
In acute AR:
1. LV not dilated nor hypertrophied is unprepared for regurgitant volume load, leading to reduced compliance, rising diastolic pressures, pushing mitral valve to close prematurely
Severe AR may cause angina even if there is no occlusive coronary disease.
Coronary perfusion occurs during diastole. Low diastolic pressure in AR causes compromised coronary perfusion
Condition is worse at night when heart rate slows and diastolic BP falls to very low levels.
How do you differentiate between carotid pulsation in the neck and JVP?
