Aortic Regurgitation

Question 1

Definition

Answer 1

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

Question 2

Aetiology/risk factors (aortic valve leaflet abnormalities/damage)

Answer 2

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

Question 3

Aetiology/risk factors (aortic root/ascending aorta dilatation)

Answer 3

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 4

Pathophysiology

Answer 4

o Reflux of blood into the left ventricle results in left ventricular dilatation

o This means increased end diastolic volume and increased stroke volume

o The combination of increased stroke volume and low end-diastolic AORTIC pressure may explain the high-volume collapsing pulse

Question 5

Epidemiology

Answer 5

· Chronic AR often begins in the late 50s

· It is most frequently seen in patients > 80 yrs

Question 6

Presenting symptoms (chronic)

Answer 6

o Initially ASYMPTOMATIC

o Later on, the patient may develop symptoms of heart failure (e.g. exertional dyspnoea, orthopnoea, fatigue)

PLUS symptoms related to aetiology

Question 7

Presenting symptoms (severe acute)

Answer 7

o Sudden cardiovascular collapse (left ventricle cannot adapt to the rapid increase in end-diastolic volume)

PLUS symptoms related to aetiology

Question 8

Signs on physical examination (pulse)

Answer 8

· Collapsing (water-hammer) pulse
· Wide pulse pressure
· Thrusting and heaving displaced apex beat

Question 9

Signs on physical examination (murmurs)

Answer 9

· Early diastolic murmur over the aortic valve region
o 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
o Heard over the apex
o Caused by turbulent reflux hitting the anterior cusp of the mitral valve causing a physiological mitral stenosis

Question 10

Signs on physical examination (rare signs)

Answer 10

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 11

Investigations

Answer 11

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

· ECG
o 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
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