Aortic Regurgitation

Question 1

Aortic Regurgitation- Definition

Answer 1

• Reflux of blood from aorta into left ventricle during diastole

Question 2

Aortic Regurgitation- Risk factors/aetiology

Answer 2

• Aortic valve leaflet abnormalities or damage
o Bicuspid aortic valve
o Infective endocarditis
o Rheumatic fever
o Trauma
• Aortic root/ascending aorta dilatation
o Systemic hypertension
o Aortic dissection
o Aortitis
o Arthritides (e.g. rheumatoid arthritis, seronegative arthritides)
o Connective tissue disease (e.g. Marfan’s, Ehlers-Danlos)
o Pseudoxanthoma elasticum
o Osteogenesis imperfecta

Question 3

Aortic Regurgitation- Pathophysiology

Answer 3

• Reflux of blood into the left ventricle results in left ventricular dilatation
• This means increased end diastolic volume and increased stroke volume
• The combination of increased stroke volume and low end-diastolic AORTIC pressure may explain the high-volume collapsing pulse

Question 4

Aortic Regurgitation- Epidemiology

Answer 4

• Chronic AR often begins in late 50s

* Frequently seen in >80yrs

Question 5

Aortic Regurgitation- Symptoms

Answer 5

• Chronic
o Initially ASYMPTOMATIC
o Later, symptoms of heart failure (exertional dyspnoea, orthopnoea, fatigue)
• Severe Acute AR
o Sudden cardiovascular collapse (left ventricle cannot adapt to the rapid increase in end-diastolic volume)
o Symptoms related to aetiology (e.g. chest or back pain caused by aortic dissection)

Question 6

Aortic Regurgitation- Signs on Exam

Answer 6

• Collapsing pulse
• Wide pulse pressure
• Thrusting and heaving displaced apex beat
• Early diastolic murmur over the aortic valve region
o Ejection systolic murmur may also be heard because of increased flow across the valve (due to increased stroke volume)
• Austin Flint mid-diastolic murmur
o Heard over the apex
o Caused by turbulent reflux hitting the anterior cusp of the mitral valve causing a physiological mitral stenosis

Question 7

Aortic Regurgitation- Rare Signs

Answer 7

o Quincke’s Sign - visible pulsation on nail bed
o de Musset’s Sign - head nodding in time with the pulse
o Becker’s Sign - visible pulsation of the pupils and retinal arteries
o Muller’s Sign - visible pulsation of the uvula
o Corrigan’s Sign - visible pulsation in the neck
o Traube’s Sign - pistol shot (loud systolic and diastolic sounds) heard on auscultation of the femoral arteries
o Duroziez’s Sign - systolic and diastolic bruit heard on partial compression of the femoral artery with the stethoscope
o Rosenbach’s Sign - systolic pulsations of the liver
o Gerhard’s Sign - systolic pulsations of the spleen
o Hill’s Sign - popliteal cuff systolic pressure exceeding brachial pressure by > 60 mm Hg

Question 8

Aortic Regurgitation- Investigations

Answer 8

• CXR
o Cardiomegaly
o Dilatation of ascending aorta
o Signs of pulmonary oedema
• ECG
o Left ventricular hypertrophy
 Deep S in V1/2
 Tall R in V5/6
 Inverted T waves in lead I, aVL, V5/6
 Left axis deviation
• Echocardiogram
o May show underlying cause (e.g. aortic root dilatation, bicuspid aortic valve)
o May show the effects of aortic regurgitation (e.g. left ventricular dilatation, fluttering of the anterior mitral valve leaflet)
o Doppler echocardiogram can show AR and indicate severity
o Repeat echos allow monitoring of progression (LV size and function)
• Cardiac catheterisation with angiography
o If there is any uncertainty about the functional state of the ventricle or the presence of coronary artery disease