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

What are the causes of aortic regurgitation?

Answer 2

Aortic valve leaflet abnormalities or damage

Aortic root/ascending aortic dilation

Question 3

What are the causes of Aortic Valve Leaflet abnormalities or damage?

Answer 3

Bicuspid aortic valve
Infective endocarditis
Rheumatic fever
Trauma

Question 4

What are the causes of Aortic root/ascending aortic dilation?

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

What is the pathophysiology of Aortic Regurgitation?

Answer 5

Reflux of blood into the left ventricle results in left ventricular dilation
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

What is the epidemiology of Aortic Regurgitation?

Answer 6

Chronic Aortic Regurgitation often begins in the late 50s

It is most frequently seen in patients > 80 yrs

Question 7

What are the presenting symptoms of Chronic Aortic Regurgitation?

Answer 7

Initially asymptomatic

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

Question 8

What are the presenting symptoms of Severe Acute Aortic Regurgitation?

Answer 8

Sudden cardiovascular collapse

left ventricle can’t adapt to the rapid increase in end-diastolic volume

Question 9

What are the symptoms of Aortic Regurgitation related to?

Answer 9

Aetiology

E.g. chest or back pain caused by Aortic Dissection

Question 10

What are the signs of Aortic Regurgitation on examination?

Answer 10

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

Question 11

Where is the Early Diastolic murmur heard best?

Answer 11

Left sternal edge when the patient is sitting forward with the breath held at the top of expiration

Question 12

What might also be heard in Aortic Regurgitation?

Answer 12

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

Question 13

Where is the Austin Flint Mid-Diastolic murmur heard?

Answer 13

Over the apex

Question 14

What is the Austin-Flint Mid-Diastolic murmur caused by?

Answer 14

Turbulent reflux hitting the anterior cusp of the mitral valve causing a physiological mitral stenosis

Question 15

What are the rare signs of Aortic Regurgitation?

Answer 15

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 16

What is Quincke’s Sign?

Answer 16

Visible pulsation on nail bed

Question 17

What is de Musset’s Sign?

Answer 17

Head nodding in time with the pulse

Question 18

What is Becker’s Sign?

Answer 18

Visible pulsation of the pupils and retinal arteries

Question 19

What is Muller’s Sign?

Answer 19

Visible pulsation of the uvula

Question 20

What is Corrigan’s Sign?

Answer 20

Visible pulsation in the neck

Question 21

What is Traube’s Sign?

Answer 21

Pistol shot (loud systolic and diastolic sounds) heard on ausculation of the femoral arteries

Question 22

What is Duroziez’s Sign?

Answer 22

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

Question 23

What is Rosenbach’s Sign?

Answer 23

Systolic pulsations of the liver

Question 24

What is Gerhard’s Sign?

Answer 24

Systolic pulsations of the spleen

Question 25

What is Hill’s Sign?

Answer 25

Popliteal Cuff Systolic Pressure exceeding brachial pressure by > 60 mm Hg

Question 26

What investigations would you do for Aortic Regurgitation?

Answer 26

CXR
ECG
Echocardiogram
Cardiac Catheterisation with angiography

Question 27

What might we see on a CXR for Aortic Regurgitation?

Answer 27

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

Question 28

What might we see on an ECG for Aortic Regurgitation?

Answer 28

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 29

What might we see on an Echocardiogram for Aortic Regurgitation?

Answer 29

May show underlying cause (e.g. aortic dilation, bicuspid aortic valve)
May show the effects of aortic regurgitation (e.g. left ventricular dilation, 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)

Question 30

Why might we do Cardiac Catheterisation with Angiography for Aortic Regurgitation?

Answer 30

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