Aortic Incompetence

Question 1

Aortic Incompetence presentation

Answer 1

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

Question 2

Clinical signs of Aortic Incompetence

Answer 2

1. Collapsing pulse (water-hammer pulse) reflecting a wide pulse pressure, e.g. 180/45
2. Apex beat is hyperkinetic and displaced laterally (TV: thrusting volume‐loaded)
3. Thrill in the aortic area
4. 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.
5. Signs of severity: collapsing pulse, third heart sound (S3) and pulmonary oedema
6. Eponymous signs

Question 3

Auscultation in Aortic Incompetence

Answer 3

• 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.

Question 4

Eponymous signs in Aortic Incompetence

Answer 4

1. Corrigan’s: visible vigorous neck pulsation
2. Quincke’s: nail bed capillary pulsation
3. De Musset’s: head nodding
4. Duroziez’s: diastolic murmur proximal to femoral artery compression
5. Traube’s: ‘pistol shot’ sound over the femoral arteries

Question 5

Congenital Causes of Aortic Incompetence

Answer 5

1. Bicuspid aortic valve;

2. Perimembranous VSD

Question 6

Acquired Causes of Aortic Incompetence

Answer 6

** Valve leaflet:
(Acute) - Endocarditis,
(Chronic) 1- Rheumatic fever or 2- Drugs: pergolide, slimming agents

**Aortic root
(Acute): 1- Dissection (type A) 2- Trauma
(Chronic): 1- Dilatation: Marfan’s and hypertension
2- Aortitis: syphilis, ankylosing spondylitis and vasculitis

Question 7

Other causes of a collapsing pulse

Answer 7

1. Pregnancy
2. Patent ductus arteriosus
3. Paget’s disease
4. Anaemia
5. Thyrotoxicosis

Question 8

Investigation in Aortic Incompetence

Answer 8

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

Question 9

Medical Management of Aortic Incompetence

Answer 9

• ACE inhibitors and ARBs (reducing afterload)

* Regular review: symptoms and echo: LVEF, LV size and degree of AR

Question 10

Indications for Surgery in Aortic Incompetence

Answer 10

Acute:
a. Dissection
b. Aortic root abscess/endocarditis (homograft preferably)
Chronic: Replace the aortic valve when:
a. Symptomatic: dyspnoea and reduced exercise tolerance (NYHA > II) AND/OR
b. The following criteria are met:
1. wide pulse pressure >100 mm Hg
2. ECG changes (on Exercise Tolerance Test)
3. Echo: LV enlargement >5.5 cm systolic diameter or EF <50% Ideally replace the valve prior to significant LV dilatation and dysfunction.

Question 11

Prognosis of Aortic Incompetence

Answer 11

• Asymptomatic with EF > 50% – 1% mortality at 5 years. - Symptomatic and all three criteria present − 65% mortality at 3 years