Aortic regurgitation

Question 1

Define aortic regurgitation.

Answer 1

Where the valve allows blood to leak back into the heart.

Diastolic murmur:
- Heard over the aortic valve.

Diastolic leakage of blood from the aorta into the left ventricle.

Question 2

What is the pathophysiology of acute AR?

Answer 2

· Medical emergency.
· High mortality - rise in left atrial pressure, pulmonary oedema and cardiogenic shock.
· Heart tries to compensate by increasing HR and contractility to keep up with increased preload, but this is insufficient to maintain the normal stroke volume and fails.

Question 3

What is the pathophysiology of chronic AR?

Answer 3

· Increase in left ventricular volume and pressure causes an increase in wall tension.
· To compensate, the heart hypertrophies.

Question 4

What is the prognosis of AR?

Answer 4

· Prognosis is good while ventricular function is good.

· Death usually occurs within 2-3 years after the onset of ventricular failure.

Question 5

What are the most common causes of AR?

Answer 5

· Cusp malformation - bicuspid valve.

· Cusp erosion - infective endocarditis.

Question 6

What are the other causes of AR?

Answer 6

· Rheumatic fever.

· Arthropathies - Ankylosing spondylitis, Marfans, aortic coarctation.

Question 7

List the common risk factors.

Answer 7

· Bicuspid aortic valve.
· Rheumatic fever.
· Endocarditis.
· Marfan’s syndrome and other connective tissue diseases.

Question 8

What are the typical symptoms of AR?

Answer 8

· Can remain asymptomatic for decades before pts present with irreversible myocardial damage.

· Dyspnoea.
· Fatigue.
· Orthopnoea. 
· PND. 
· Mottled extremities. 
· JVD (jugular venous distension).
· Basal lung crepitations.

Question 9

What are the typical signs of AR?

Answer 9

· Head bobbing / de Musset’s sign.
· Soft, early diastolic murmur best heard in expiration with the breath held.
· Collapsing ‘water hammer’ pulse.
· Wide pulse pressure and low diastolic.

Question 10

What 4 investigations would you request if you suspected a patient had AR?

Answer 10

· ECG.
· CXR.
· ECHO.
· Colour flow doppler.

Question 11

List some differentials.

Answer 11

· Pulmonary regurgitation.
· Mitral regurgitation or stenosis.
· Aortic stenosis.

Question 12

What are the treatment options for acute AR?

Answer 12

· Inotropes.
· Vasodilators.
· Urgent aortic valve replacement/repair.

Question 13

What are the treatment options for chronic AR?

Answer 13

· Reassurance.
· Vasodilator therapy.
· Transcatheter aortic valve implantation (TAVI).

Question 14

Suggest some complications that can occur.

Answer 14

· Operative mortality. 
· CHF. 
· Arrhythmias. 
· Infective endocarditis.
· Sudden death.
· Myocardial ischaemia.