Aortic regurgitation

Question 1

Define aortic regurgitation

Answer 1

Reflux of blood from the aorta into the left ventricle during diastole

(AKA aortic insufficiency)

Question 2

Epidemiology of aortic regurgitation

chronic age, general age

Answer 2

Chronic AR often begins in late 50s

Most frequently seen in over 80s

Question 3

Aetiology of aortic regurgitation

2 groups

Answer 3

Aortic valve leaflet abnormalities or damage

Aortic root/ascending aorta dilatation

Question 4

Aetiology of aortic regurgitation - aortic valve leaflet abnormalities or damage
(4)

Answer 4

Bicuspid aortic valve
Infective endocarditis
Rheumatic fever
Trauma

Question 5

Aetiology of aortic regurgitation - aortic root/ascending aorta dilatation
(7)

Answer 5

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 6

Pathophysiology of aortic regurgitation

3

Answer 6

Reflux of blood into left ventricle results in left ventricle dilatation
—> increased end diastolic volume & increased stroke volume
The increased stroke volume & low end-diastolic AORTIC pressure may explain high volume collapsing pulse

Question 7

Presenting symptoms of aortic regurgitation

general + 2 groups

Answer 7

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

Chronic AR
Severe acute AR

Question 8

Presenting symptoms of aortic regurgitation - chronic

2

Answer 8

Initially ASYMPTOMATIC

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

Question 9

Presenting symptoms of aortic regurgitation - severe acute

Answer 9

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

Question 10

Signs of of aortic regurgitation on physical examination

6

Answer 10

Collapsing (water-hammer) pulse

Wide pulse pressure

Thrusting & heaving displaced apex beat

Early diastolic murmur
heard over aortic valve region
heard better at left sternal edge when patient is sitting forward w/ breath held at top of expiration

Ejection systolic murmur may be heard
due to increased blood flow across valve (due to increased stroke volume)

Austin Flint mid-diastolic murmur
heard over apex
caused by turbulent reflux hitting anterior cusp of mitral valve causing physiological mitral stenosis

Question 11

Signs of of aortic regurgitation on physical examination - RARE
(10)

Answer 11

Quincke’s sign - visible pulsation on nail bed
de Musset’s sign - head nodding in time w/ pulse
Becker’s sign - visible pulsation of pupils & retinal arteries
Muller’s sign - visible pulsation of uvula
Corrigan’s sign - visible pulsation of neck
Traube’s sign - pistol shot (loud systolic & diastolic sounds) heard on auscultation of femoral arteries
Duroziez’s sign - systolic & diastolic bruit heard on partial compression of femoral artery w/ stethoscope
Rosenbach’s sign - systolic pulsations of liver
Gerhard’s sign - systolic pulsations of spleen
Hill’s sign - popliteal cuff systolic pressure exceeding brachial pressure by >60 mm Hg

Question 12

Investigations for aortic regurgitation

4 groups

Answer 12

CXR
ECG
Echocardiogram
Cardiac catheterisation w/ angiography

Question 13

Investigations for aortic regurgitation - CXR

3

Answer 13

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

Question 14

Investigations for aortic regurgitation - ECG

4

Answer 14

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 15

Investigations for aortic regurgitation - echocardiography

4

Answer 15

May show underlying cause (e.g. aortic root dilatation, bicuspid aortic valve)
May show effects of aortic regurgitation (e.g. left ventricular dilatation, fluttering of anterior mitral valve leaflet)
Doppler echocardiogram can show AR & indicate severity
Repeat echoes allow monitoring of progression (LV size & function)

Question 16

Investigations for aortic regurgitation - cardiac catheterisation w/ angiography

Answer 16

If there’s any uncertainty about functional state of ventricle or presence of coronary artery disease