Aortic regurgitation
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Aortic regurgitation
![Aortic Regurgitation: overview
ο AR is a condition due to inadequate closure of the aortic
valve leaflets leading to abnormal retrograde flow of
blood through the aortic valve during cardiac diastole.
ο It can be induced either by damage to and dysfunction of
the aortic valve leaflets or by distortion or dilatation of
the aortic root and ascending aorta
ο In the developing world, the most common cause of AR is
rheumatic heart disease. However, in developed
countries, AR is most often due to aortic root dilation or a
congenital bicuspid aortic valve .[1]](data:image/gif;base64,R0lGODlhAQABAIAAAAAAAP///yH5BAEAAAAALAAAAAABAAEAAAIBRAA7)
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Aortic regurgitation
- 2. Aortic Regurgitation: overview ο AR is a condition due to inadequate closure of the aortic valve leaflets leading to abnormal retrograde flow of blood through the aortic valve during cardiac diastole. ο It can be induced either by damage to and dysfunction of the aortic valve leaflets or by distortion or dilatation of the aortic root and ascending aorta ο In the developing world, the most common cause of AR is rheumatic heart disease. However, in developed countries, AR is most often due to aortic root dilation or a congenital bicuspid aortic valve .[1]
- 3. Causes of Aortic Regurgitation Leaflet abnormalities Aortic root or ascending aorta Rheumatic fever Systemic hypertension Endocarditis Aortitis (eg, syphilis) Trauma Bicuspid aortic valve Ankylosing spondylitis Trauma/ Dissecting aneurysm Marfan syndrome/ EDS Inflammatory bowel disease AR is seen more commonly in men than in women.
- 4. Pathophysiology of aortic regurgitation Aortic regurgitation LV volume LV mass LV dysfunction LV failure stroke volume Systolic BP Diastolic BP Wide pulse pressure hyperdynamic circulation
- 5. ο Palpitation ο Initial symptom due to vigrous contraction of volume overload LV ο Angina ο Less common as C/F AS ο Dyspnoea ο Initially on exertion ο PND Clinical history
- 6. Physical finding ο Pulse ο Very good volume & wide pulse pressure ο Rapid rise & collapse with markedly ed pulse pressure (water hammer pulse / Corrigan pulse)
- 7. Findings are a/w hyperdynamic pulse deMusset's sign A head bob occurring with each cardiac cycle Mueller's sign Systolic pulsations of the uvula. Landolfi sign Change in size of pupil with each beat Quincke's pulses visible Capillary pulsations in the nailbeds after holding the tip of the nail. Traube's sign A pistol shot murmur (systolic and diastolic sounds) heard over the femoral arteries. Duroziez's sign A systolic and diastolic bruit heard when the femoral artery is partially compressed.to and fro murmur Hill's sign Normal BP in LL > UL Normal difference is up to 20 In AR the difference > 20
- 8. Auscultation ο Early diastolic murmur ο Best heard LSB left 3rd /4th ICS with patient sitting & leaning forward
- 9. Lab investigation ο CXR ο Cardiomegaly ο ECG ο LV hypertrophy ο Echo ο Confirm the diagnosis
- 10. Treatment ο Medical treatment (for heart failure) - Diuretics, Digoxin, salt restriction - Vasodilators - Endocarditis prophylaxis ο Surgical treatment (in severe cases) ο AVR .
Editor's Notes
- AR is a condition due to inadequate closure of the aortic valve leaflets leading to abnormal retrograde flow of blood through the aortic valve during cardiac diastole.
- AR may be caused by either valvular or aortic root pathology. Valvular abnormalities that may result in AR include bicuspid aortic valve (the most common congenital cause), rheumatic fever, infective endocarditis, collagen vascular diseases, and degenerative aortic valve disease. Abnormalities of the ascending aorta, in the absence of valve pathology, may also cause AR, such as may occur with longstanding uncontrolled hypertension, Marfan syndrome, idiopathic aortic dilation, syphilitic aortitis, giant cell arteritis, Takayasu arteritis, ankylosing spondylitis, Whipple disease, and other spondyloarthropathies. The absence of a wide pulse pressure and of the characteristic arterial auscultatory signs of chronic AR in patients with acute AR is thought to be due to the much higher LV end-diastolic pressure (LVEDP) in the acute form. The acute development of a severe aortic valvular leak causes a much higher LVEDP in the normal-sized LV of patients with acute AR. Patients with chronic AR commonly have a dilated LV with increased compliance capable of accommodating large blood volumes without a significant rise of LVEDP.
- Sherman sign ; prominently located and palpated dorsalis pedis pulse Landolfi sign: alternating constriction and dilatation of pupil Duroziez sign: systolic portion of murmur was caused by forward flow into the lower extremity and the diastolic segment was caused by aortic regurgitation towards the heart. Seagull murmur: it is murmur with musical qualities such as that heard occasionally in aortic insufficiency. A sea gull cry murmur is defined as a murmur imitating the cooing sound of a seagull.this type of murmur is typically characterised by a music timbre and a high frequency and may occur as a result of various valve disease.it is usually described as a sign of tight calcific aortic stenosis when the murmur high frequency components are transmitted to the lower left sternal border and the cardiac apex during most of the systole (gallavardin phenomenon).in this condition,the typical harsh timbre of the ejective murmur tends to assume a musical high pitched quality ,resembling that of mitral regurgitation which may be reminiscent of the cry of a seagull. A protodiastolic murmur with similar characteristics ,typically in decrescendo ,may occur in severe AR particularly when the flow presents high velocities. However, a seagulls cry murmur may also be the sign of MR or prolapse. Similarly the muscial and holosystolic sound reflects the presence of high frequency components due to high velocities of reflow.