Aortic Regurgitation

Question 1

Symptoms

Answer 1

1. None (can be the case even if severe)
2. Breathlessness (most common)
3. Chest pain
4. Symptoms of heart failure as progresses

Question 2

Signs

Answer 2

Common:

• collapsing pulse
• wise pulse pressure
• corrigans pulse
• displaced apex beat
• early diastolic murmur ( normally loudest LSE but may be aortic if aortic dilatation) (as the lesion becomes more severe, the murmur shortens - as back flow is more severe, LV diastolic pressure rises faster, therefore pressure gradient between sort and LV diminishes faster)

Uncommon

• de mussets sign
• duroziers sign
• quinckes sign

Question 3

Formal definition of collapsing pulse pressure

Answer 3

Pulse pressure is greater than diastolic pressure

AKA systolic pressure is twice that of diastolic pressure

Question 4

Aetiology

Answer 4

Acute:

1. IE
2. Aortic dissection
3. Prosthetic valve failure
4. Ruptured sinus of valsalva (rare)
5. Acute rheumatic fever

Chronic

6. Bicuspid aortic valve
7. Marfans syndrome
8. Rheumatic heart disease
9. Endocarditis
10. Aorto-annular ectasia (dilation both proximal ascending aorta and aortic annulus. Connective tissue disease, tertiary syphilus)
11. Tertiary syphilus
12. Seronegative arthritides (such as ankylosing spondylitis)
13. Osteogenesis imperfects

Question 5

Differential diagnosis

Answer 5

Pulmonary regurgitation - murmur not loudest at LLSE and none of other signs

Question 6

Associated conditions

Answer 6

As per aetiology

• marfans
• endocarditis
• ank spond (apical fine creps)
• coarctation aorta

Question 7

Investigations

Answer 7

1. Echo - dx and grading

2. CMR - can accurately quantify EF, LV dimensions and particularly regurgitant fraction

Question 8

Management

Answer 8

Acute
- surgery if anything more than mild
Chronic
- replacement if symptoms
- medical management (ACR-i and diuretics) if asymptomatic unless:
- replacement if asymptomatic and:
1. Significant LV dilatation (LVEDD >70mm, LVESD >50mm)
2. EF <50mm
3. Significant aortic root dilatation (>45mm if marfans, >50 MDM if bicuspid or >55mm otherwise
4. Those undergoing any other cardiac surgery
5. Regurgitant fraction >50%

Question 9

Complications

Answer 9

Endocarditis

Heart failure

Question 10

What clinical findings suggest severe AR?

Answer 10

1. Clinically dilated heart
2. Signs of left heart failure
3. Very wide pulse pressure
4. Shorter murmur