Aortic regurgitation

Question 1

Define aortic regurg.

What is another term for it?

Answer 1

The reflux of blood from the aorta into the left ventricle during diastole. Also known as aortic insufficiency

Question 2

Explain the aetiology and risk factors of aortic regurgitation.

Answer 2

1. Aortic valve leaflet abnormalities or damage
   - infective endocarditis
   - bicuspid aortic valve
   - rheumatic fever
   - trauma
2. Ascending aorta dilatation
   - Systemic hypertension
   - Aortic dissection
   - Aortitis
   - rheumatoid arthritis, seronegative arthritides)
   - Connective tissue disease (e.g. Marfan’s, Ehlers-Danlos)
   - Pseudoxanthoma elasticum
   - Osteogenesis imperfecta

Question 3

Why does aortic regurg cause a high volume collapsing pulse?

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

Summarise the epidemiology of aortic regurgitation

Answer 4

Chronic AR often begins in the late 50s

It is most frequently seen in patients > 80 yrs

Question 5

Recognise the presenting symptoms of aortic regurgitation

Answer 5

Principle sx is SOB

Chronic AR;
Initially ASYMPTOMATIC

Later on, the patient may develop symptoms of heart failure; Dyspnoea on exertion, orthopnoea, fatigue.

Severe Acute AR;
Sudden cardiovascular collapse (left ventricle cannot adapt to the rapid increase in end-diastolic volume)

Symptoms related to aetiology (e.g. chest or back pain caused by aortic dissection)

Question 6

Recognise the signs of aortic regurgitation on examination

Answer 6

1. Collapsing pulse
2. Wide pulse pressure
3. Thrusting and heaving displaced apex beat
4. Early diastolic murmur over the aortic valve region
   - Heard better at the left sternal edge when the patient is sitting forward with the breath held at the top of expiration
5. Austin Flint mid-diastolic murmur
   - Heard over the apex
   - Caused by turbulent reflux hitting the anterior cusp of the mitral valve causing a physiological mitral stenosis

Soft 2nd HS

NOTE: an ejection systolic murmur may also be heard because of increased flow across the valve (due to increased stroke volume)

Question 7

Name some rare signs of aortic regurg?

Answer 7

Rare signs associated with aortic regurgitation:

Quincke’s Sign - visible pulsation on nail bed
Muller’s Sign - visible pulsation of the uvula

Corrigan’s Sign - visible pulsation in the neck

Rosenbach’s Sign - systolic pulsations of the liver

de Musset’s Sign - head nodding in time with the pulse

Becker’s Sign - visible pulsation of the pupils and retinal arteries

Traube’s Sign - pistol shot (loud systolic and diastolic sounds) heard on auscultation of the femoral arteries

Duroziez’s Sign - systolic and diastolic bruit heard on partial compression of the femoral artery with the stethoscope

Gerhard’s Sign - systolic pulsations of the spleen

Hill’s Sign - popliteal cuff systolic pressure exceeding brachial pressure by > 60 mm Hg

Question 8

Identify appropriate investigations for aortic regurgitation

Answer 8

CXR - cardiomegaly, dilated aortic root, pulmonary congestion
ECG - LVH (by voltage criteria)
ECHO - gold
Cardiac catheteriation with angiography

Question 9

What would the investigations for aortic regurgitation show?

Answer 9

CXR

Cardiomegaly

Dilatation of ascending aorta

Signs of pulmonary oedema (if accompanied by left heart failure)

ECG

May show 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

May show underlying cause (e.g. aortic root dilatation, bicuspid aortic valve)

May show the effects of aortic regurgitation (e.g. left ventricular dilatation, fluttering of the anterior mitral valve leaflet)

Doppler echocardiogram can show AR and indicate severity

Repeat echos allow monitoring of progression (LV size and function)

Cardiac catheterisation with angiography

If there is any uncertainty about the functional state of the ventricle or the presence of coronary artery disease

Question 10

MX?

Answer 10

Reassurance and treat underlying cause eg htn

Surgery if:

1. Symptomtic AR
2. Asymptomatic AR with impaired LV function (eg EF<50%)

Valve is replaced - or
TAVI’s not possible