Aortic regurgitation

AORTIC REGURGITATION (AR)

 ETIOLOGY

1 . Rheumatic fever (most common cause)

2. Infective endocarditis

3. Bicuspid aortic valve

4. Large VSD

5. SLE

6. Ankylosing spondylitis

7. Rheumatoid arthritis

8. Takayasu disease

9. Whipple disease

10. Crohn’s disease

11.  Marfan’s syndrome (cystic medial necrosis of aorta)

12. Dissection of the aorta

13 . Syphilitic aortitis

14. Ankylosing spondylitis

15. Failure of the prosthetic heart valve

16. .Severe hypertension.

Symptoms

Could be asymptomatic

Palpitations

Shortness of breath

Chest pain

Signs

Inspection

Prominent pulsations over the pericardium

Apex beat displaced outside midclavicular line

Palpation

Apex beat palpable outward and downward displaced- Heaving character due to LVH

Diastolic thrill at the left sternal edge

Auscultation

Soft SI due to prolonged PR interval

A2 may be soft or absent

P2 may be obscured by diastolic murmur, therefore S2 may be single or absent.

S4 is often audible.

Murmur

Early diastolic murmur best heard at the second aortic area (A2), located in left third intercostals space close to the sternum particularly when the patient sits, leans forwards, and holds his breath after expiration. Prolonged the murmur, severe is the AR.

A systolic ejection murmur may be present in the aortic area due to a high flow state.

Austin-Flint murmur: It is a mid-diastolic Murmur heard at the apex. It is produced as a result of backward leakage of blood from the aortic valve (during diastole) that pushes the anterior leaflet of the mitral valve towards the mitral opening. It produces a “functional mitral stenosis” producing a mid-diastolic murmur.

The pistol shot femoral: A sharp sound heard on auscultation over the femoral arteries in time with each heartbeat.

Duroziez’s sign bruit heard over femoral arteries on light compression by stethoscope.

General physical examination related to AR

Pulse: —  Water hammer pulse. This is of high volume and bounding or collapsing (water-hammer) in character. The following signs are rare but may be present.

Quincke’s sign: Capillary pulsation in the nail beds.

De Musset’s sign: The carotid pulsations are so forceful that the head moves with them, also called nodding of the head.

Corrigen’s sign: Carotid pulsation may be very prominent (dancing carotid).

Blood pressure —Systolic arterial pressure is increased with low diastolic pressure. It is due to a large stroke volume, whereas the diastolic pressure is decreased due to regurgitation of blood from the aorta to the ventricle. Therefore pulse pressure is increased (the difference between systolic and diastolic BP is more than 60 mmHg). You will be surprised when the reading of diastolic blood pressure is zero.

INVESTIGATIONS

X-ray chest – This shows left ventricular enlargement and dilatation of the ascending aorta.

ECG — It shows features of left ventricular hypertrophy.

Echocardiography

Cardiac catheterization and angiography

Medical treatment

Vasodilators

ACE inhibitors