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

Explain the aetiology and risk factors of aortic regurgitation

Answer 2

Aortic valve leaflet abnormalities or damage:
Bicuspid aortic valve
Infective endocarditis
Rheumatic fever
Trauma

Aortic root/ascending aorta dilatation:
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

Pathophysiology:
Reflux of blood into the left ventricle results in left ventricular dilatation. 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 3

Summarise the epidemiology of aortic regurgitation

Answer 3

Chronic AR often begins in the late 50s

It is most frequently seen in patients > 80 yrs

Question 4

Recognise the presenting symptoms of aortic regurgitation

Answer 4

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

Severe Acute AR
Sudden cardiovascular collapse (left ventricle cannot adapt to the rapid increase
in end-diastolic volume)

Symptoms related to aetiology (e.g. chest or back pain caused by aortic dissection

Question 5

Recognise the signs of aortic regurgitation on examination

Answer 5

Collapsing (water-hammer) pulse

Wide pulse pressure

Thrusting and heaving displaced apex beat

Early diastolic murmur over the aortic valve region
(Heard better at the left sternal edge when the patient is sitting forward with the breath held at the top of expiration)

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

Austin Flint mid-diastolic murmur (Heard over the
apex) Caused by turbulent reflux hitting the anterior cusp of the mitral valve causing a physiological mitral stenosis

Question 6

Rare signs associated with aortic regurgitation:

Answer 6

Quincke’s Sign- visible pulsation on nail bed

de Musset’s Sign-head nodding in time with the pulse

Becker’s Sign-visible pulsation of the pupils and retinal arteries

Muller’s Sign-visible pulsation of the uvula

Corrigan’s Sign-visible pulsation in the neck

Traube’s Sign -pistol shot (loud systolic and diastolic sounds) heard on
auscultation of the femoral arteries

Duroziez’s Sign - systolic and diastolic bruit heard on partial compression of the femoral artery with the stethoscope

Rosenbach’s Sign- systolic pulsations of the liver

Gerhard’s Sign- systolic pulsations of the spleen

Hill’s Sign-popliteal cuff systolic pressure exceeding brachial pressure by > 60mm Hg

Question 7

Identify appropriate investigations for aortic regurgitation

Answer 7

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

ECG - 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

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

Cardiac catheterisation with angiography - If there is any uncertainty about the functional state of the ventricle or the presence of coronary artery disease