Aortic Regurgitation

Question 1

Define Aortic Regurgitation

Answer 1

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

Question 2

The aetiology and risk factors of aortic regurgitation

Answer 2

Aortic valve leaflet abnormalities or damage

Aortic root/ascending aorta dilatation

Question 3

Aortic valve leaflet abnormalities or damage

Answer 3

Bicuspid aortic valve

Infective endocarditis

Rheumatic fever

Trauma

Question 4

Aortic root/ascending aorta dilatation

Answer 4

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 5

Pathophysiology

Answer 5

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 6

Summarise the epidemiology of aortic regurgitation

Answer 6

Chronic AR often begins in the late 50s

It is most frequently seen in patients > 80 yrs

Question 7

Recognise the presenting symptoms of aortic regurgitation

Answer 7

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 8

Recognise the signs of aortic regurgitation on examination

Answer 8

Collapsing (water-hammer) pulse
Wide pulse pressure
Thrusting and heaving displaced apex beat
Early diastolic murmur over the aortic valve region
Austin Flint mid-diastolic murmur

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

Question 9

Austin Flint mid-diastolic murmur

Answer 9

Heard over the apex

Caused by turbulent reflux hitting the anterior cusp of the mitral valve causing a physiological mitral stenosis

Question 10

Rare signs associated with aortic regurgitation:

Answer 10

Quincke's Sign
de Musset's Sign 
Becker's Sign
Muller's Sign
Corrigan's Sign
Traube's Sign 
Duroziez's Sign
Rosenbach's Sign
Gerhard's Sign -
Hill's Sign

Question 11

Quincke’s Sign

Answer 11

visible pulsation on nail bed

Question 12

de Musset’s Sign

Answer 12

head nodding in time with the pulse

Question 13

Becker’s Sign

Answer 13

visible pulsation of the pupils and retinal arteries

Question 14

Muller’s Sign

Answer 14

visible pulsation of the uvula

Question 15

Corrigan’s Sign

Answer 15

visible pulsation in the neck

Question 16

Traube’s Sign

Answer 16

pistol shot (loud systolic and diastolic sounds) heard on auscultation of the femoral arteries

Question 17

Duroziez’s Sign

Answer 17

systolic and diastolic bruit heard on partial compression of the femoral artery with the stethoscope

Question 18

Rosenbach’s Sign

Answer 18

systolic pulsations of the liver

Question 19

Gerhard’s Sign

Answer 19

systolic pulsations of the spleen

Question 20

Hill’s Sign

Answer 20

popliteal cuff systolic pressure exceeding brachial pressure by > 60 mm Hg

Question 21

Identify appropriate investigations for aortic regurgitation

Answer 21

CXR
ECG
Echocardiogram
Cardiac catheterisation with angiography

Question 22

CXR

Answer 22

• Cardiomegaly
• Dilatation of ascending aorta
• Signs of pulmonary oedema (if accompanied by left heart failure)

Question 23

ECG

Answer 23

• 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

Question 24

Echocardiogram

Answer 24

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 echoes allow monitoring of progression (LV size and function)

Question 25

Cardiac catheterisation with angiography

Answer 25

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