Station 3.2: Aortic incompetence

Question 1

Clinical signs

What are the clinical signs of Aortic incompetence?

Aortic incompentence

This patient has been referred by his GP with ‘a new murmur’. He is asymptomatic. Please examine his cardiovascular system and diagnose his problem.

Answer 1

• Collapsing pulse (waterhammer pulse) reflecting a wide pulse pressure, e.g. 180/45
• Apex beat is hyperkinetic and displaced laterally (TV: thrusting volume‐loaded)
• Thrill in the aortic area
• Auscultation:
  ⚬ Early diastolic murmur (EDM) loudest at the lower left sternal edge with the patient sat forward in expiration.
  ⚬ There may be an aortic flow murmur and a mid-diastolic murmur (MDM) (Austin–Flint) due to regurgitant flow impeding mitral opening.
  ⚬ In severe AR there may be ‘free flow’ regurgitation and the EDM may be silent.
• Signs of severity: collapsing pulse, third heart sound (S3) and pulmonary oedema
• Eponymous signs
  ⚬ Corrigan’s: visible vigorous neck pulsation
  ⚬ Quincke’s: nail bed capillary pulsation
  ⚬ De Musset’s: head nodding
  ⚬ Duroziez’s: diastolic murmur proximal to femoral artery compression
  ⚬ Traube’s: ‘pistol shot’ sound over the femoral arteries

Question 2

Discussion - Causes

What are the causes of Aortic incompetence?

Aortic incompentence

This patient has been referred by his GP with ‘a new murmur’. He is asymptomatic. Please examine his cardiovascular system and diagnose his problem.

Answer 2

• Congenital: bicuspid aortic valve; perimembranous VSD
• Acquired:

===================================================
………………………………..Acute………………..Chronic
Valve leaflet……..Endocarditis………..Rheumatic fever
……………………………………………………………………Drugs: pergolide, slimming agents
Aortic root……..Dissection (type A)………….Dilation: Marfan’s and hypertension
……………………………….Trauma………………………Aortitis: syphilis, ankylosing spondylitis and vasculitis

Question 3

Discussion - Causes

What are Other causes of a collapsing pulse of Aortic incompetence?

Aortic incompentence

This patient has been referred by his GP with ‘a new murmur’. He is asymptomatic. Please examine his cardiovascular system and diagnose his problem.

Answer 3

• Pregnancy
• Patent ductus arteriosus
• Paget’s disease
• Anaemia
• Thyrotoxicosis

Question 4

Discussion - Investigation

What Investigations required for Aortic incompetence?

Aortic incompentence

This patient has been referred by his GP with ‘a new murmur’. He is asymptomatic. Please examine his cardiovascular system and diagnose his problem.

Answer 4

• ECG: lateral T‐wave inversion
• CXR: cardiomegaly, widened mediastinum and pulmonary oedema
  TTE/TOE:
  ⚬ Severity: LVEF and dimensions, root size, jet width
  ⚬ Cause: intimal dissection flap or vegetation
• Cardiac catheterization: grade severity aortogram and check coronary patency

Question 5

Discussion - Management

What Investigations required for Aortic incompetence?

Aortic incompentence

This patient has been referred by his GP with ‘a new murmur’. He is asymptomatic. Please examine his cardiovascular system and diagnose his problem.

Answer 5

Medical
* ACE inhibitors and ARBs (reducing afterload)
* Regular review: symptoms and echo: LVEF, LV size and degree of AR

Surgery
Acute:
* Dissection
* Aortic root abscess/endocarditis (homograft preferably)

Chronic:
Replace the aortic valve when:
* Symptomatic: dyspnoea and reduced exercise tolerance (NYHA > II) AND/OR
* The following criteria are met:
1. wide pulse pressure >100mm Hg
2. ECG changes (on ETT)
3. echo: LV enlargement >5.5cm systolic diameter or EF <50%

Ideally replace the valve prior to significant left ventricular dilatation and dysfunction.

Question 6

Discussion - Management

What Investigations required for Aortic incompetence?

Aortic incompentence

This patient has been referred by his GP with ‘a new murmur’. He is asymptomatic. Please examine his cardiovascular system and diagnose his problem.

Answer 6

Medical
* ACE inhibitors and ARBs (reducing afterload)
* Regular review: symptoms and echo: LVEF, LV size and degree of AR

Surgery
Acute:
* Dissection
* Aortic root abscess/endocarditis (homograft preferably)

Chronic:
Replace the aortic valve when:
* Symptomatic: dyspnoea and reduced exercise tolerance (NYHA > II) AND/OR
* The following criteria are met:
1. wide pulse pressure >100mm Hg
2. ECG changes (on ETT)
3. echo: LV enlargement >5.5cm systolic diameter or EF <50%

Ideally replace the valve prior to significant left ventricular dilatation and dysfunction.