Aortic Regurgitation

Question 1

What is the definition of aortic regurgitation?

Answer 1

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

Question 2

What is the aetiology of aortic regurgitation?

Answer 2

Aortic valve leaflet abnormalities or damage

• Bicuspid aortic valve
• Infective endocarditis
• Rheumatic fever
• Trauma

Aortic root/ascending aorta dilatation

• Systemic hypertension
• Aortic dissection
• Aortitis
• Arthritides (e.g. rheumatoid arthritis, seronegative arthritides)
• Connective tissue disease (e.g. Marfan’s, Ehlers-Danlos)
• Pseudoxanthoma elasticum
• Osteogenesis imperfecta

Question 3

What is the pathophysiology of aortic regurgitation?

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

What is 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

What are the presenting symptoms associated with aortic regurgitation?

Answer 5

Chronic AR

• Initially ASYMPTOMATIC
• Later on, the patient may develop symptoms of heart failure (e.g. exertional dyspnoea, 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

What are the signs associated with aortic regurgitation upon examination?

Answer 6

Collapsing (water-hammer) pulse

Wide pulse pressure

Thrusting and heaving displaced apex beat

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

Austin Flint mid-diastolic murmur

Question 7

What is an Austin-Flint murmur?

Answer 7

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

Question 8

What are the rare signs associated with aortic regurgitation?

Answer 8

Quincke’s Sign - visible pulsation on nail bed

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

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

Muller’s Sign - visible pulsation of the uvula

Corrigan’s Sign - visible pulsation in the neck

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

Rosenbach’s Sign - systolic pulsations of the liver

Gerhard’s Sign - systolic pulsations of the spleen

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

Question 9

What are the appropriate investigations for aortic regurgitation?

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