Download Aortic Regurgitation Causes Clinical Features Signs of Severity

Aortic Regurgitation
Causes
Valvular disease
- Congenital bicuspid aortic
valve
Clinical Features
Asymptomatic
- Normal LV function
- Abnormal LV function
o 1/3 Normal, 1/3 AS, 1/6 AR, 1/6
IE  AR
- Rheumatic Heart Disease
- Infective Endocarditis*
- Drugs
o Ergot-derived compounds
o Slimming pills
- Congenital septal defects:
o Ostim primum ASD
o Supracristal VSD
o Rate of progression to
symptomatic AR: 25%/year
Symptomatic: [Mortality >10%/yr!]
- Exertional Dyspnea
o Excess preload  LV dilation &
hypertrophy  LVEF is preserved
initially  Failure of compensatory
mechanism  LV systolic
dysfunction  ↑LV diastolic
pressure  Dyspnea
Angina
- Symptoms of Heart Failure
- Others: Valvulitis (e.g. RA, SLE)
-
Aortic Root disease
- Ankylosing spondylitis
- Hypertension
Note:
- Sudden death is less common in AR than
in AS
o Systemic hypertension  Aortic
root dilation
- Marfan syndrome
- Aortitis
o Tertiary Syphilis, Takayasu’s
arteritis, Giant Cell Arteritis,
Rheumatoid/reactive arthritis
Peripheral Signs:
- Corrigan’s sign:
o Visible carotid pulsations
- Muller’s sign:
o Uvula pulsations
- Dissection/Aneurysm*
- De Musset’s sign:
*Causes of Acute aortic
regurgitation
- Short diastolic murmur,
Classical signs of AR often
absent (e.g. collapsing pulse)
- Very sick patients – Present as
tachycardia, tachypnea,
pulmonary edema, cardiogenic
shock
o Compensation
mechanisms (e.g. LV
dilation) has not yet
occurred  ↑↑ backpressure causing
pulmonary congestion 
↓↓ ventricular outflow
causing cardiogenic shock
- Quincke’s:
o Head nodding in time with heart
beat
o Capillary pulsation in fingernails
- Traube’s:
o Pistol-shots heard over femoral
pulse
- Duroziez’s:
o To-and-fro systolic & diastolic
murmur on compression over
femorals
- Hill’s
o Popliteal SBP > Brachial SBP by
≥20mmHg
Signs of Severity
Murmur characteristics:
- Long EDM
o Length of murmur is
proportional to severity of
lesion!
- Soft S2
o Due to loss of A2
- Presence of S3
o Aortic regurgitation  Rapid
diastolic filling of ventricles
- Austin Flint murmur
o Mid-diastolic murmur heard
best at apex
o Physiologic “Mitral Stenosis”
due to ↑ in LV diastolic
pressure
o Retrograde regurgitant flow
from aorta compete with
Antegrade flow from LA
Pulse/Apex beat:
- Displaced apex beat
- Collapsing pulse
- Wide pulse pressure
Complications:
- Cardiac failure
Staging of Valvular Heart
Disease
- Stage A: At Risk
o Patients with risk factors for
developing valvular heart
disease
- Stage B: Progressive
o Asymptomatic mild-tomoderate valvular heart
disease
- Stage C: Asymptomatic
Severe
o C1: Compensated LV/RV
function (e.g. LVEF >50%)
o C2: Decompensated LV/RV
function (e.g. LVEF<50%)
- Stage D: Symptomatic
Severe
Investigations
Echocardiography
- Assess Morphology
o Determine Valvular vs Aortic root
problem
o Determine Etiology: Bicuspid valve,
Infective endocarditis (Vegetation)
- Assess Severity
- Assess LV Size & Function
Electrocardiogram
- Left Ventricular Hypertrophy
without strain pattern
Management
Acute Aortic Regurgitation
Consider ischemia and endocarditis as
possible precipitants
Urgent surgery required for acute aortic
regurgitation (poorly tolerated by LV)
IV Nitroprusside for afterload reduction
IV Dobutamine for inotropic support
(cf. aortic stenosis – LVH + Strain)
Chest X-ray
- Cardiomegaly
o Due to LV dilation (inferior &
leftward enlargement)
- Dilated ascending aorta
- Aortic aneurysm/dissection
Chronic Aortic Regurgitation
Medical Management
Regular follow-up for development of
symptoms and serial echocardiography
Vasodilators (e.g Nifedipine, ACE-I/ARB,
Hydralazine)
Treatment of underlying cause
Treatment of complications
Avoid:
- Beta-blockers
o Bradycardia  Prolongation of diastole  ↑
Regurgitant volume
Surgical
Aortic Valve Replacement
- Indications:
o Severe aortic regurgitation
o + 1 of the following:
 Symptomatic [D]
 Note: Survival rates drop drastically
with onset of symptoms! – hence
intervention is needed!!
 Note: If symptomatic but not severe,
symptoms unlikely to be due to aortic
regurgitation!
Ejection Fraction <50% [C2]

 Undergoing other cardiac
surgery [C1,C2, D]
(e.g. CABG, Aortic root surgery, Mitral
valve repair)
[Class I Recommendation based on ACC/AHA 2014
guidelines]
Presentation:
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Sir, this patient presents with aortic regurgitation as evidenced by:
Auscultation findings
o End-diastolic murmur heard loudest over the lower left sternal edge
o Loudest at end expiration with patient sitting forwards
o Grade 3/6 murmur with no diastolic thrill
Severity
o Additional heart sounds: Third heart sound (S3)
o Additional murmurs: Mid-diastolic murmur at the apex (Austin-Flint murmur)
o Apex beat was displaced and located at 6th intercostal space, anterior axillary line, thrusting in nature
o Heart rate is ___/minute, regular rhythm, bounding character
 Presence of Collapsing pulse and Brachial dance
 Positive Corrigan’s sign
Complications
o Pulmonary hypertension
o Atrial fibrillation
o Congestive Cardiac Failure
o Endocarditis
Etiology
o High-arch palate/Marfanoid habitus
o Symmetrical deforming polyarthropathy of hands to suggest rheumatoid arthritis
Treatment
o Sternotomy/Thoracotomy scars
Request
o Vitals & Temperature charts
o Palpate the peripheral pulses
 & Auscultate over the femoral pulse for Traube’s and Duroziez’s sign
o Blood pressure
 Wide pulse pressure
 Hill’s sign (LL SBP > UL SBP)
 Systemic hypertension
o Fundoscopy for Roth spots
 & Examine eyes (for Argyll-Robertson pupils)
o Urine dipstick analysis for Microscopic hematuria