Aortic regurgitation no-video
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Aortic regurgitation no-video
- 1. AORTIC REGURGITATION Jose James Final Year MBBS M1 Unit
- 2. Introduction •Aortic regurgitation (AR), also known as Aortic insufficiency (AI), is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle. As a consequence, the cardiac muscle is forced to work harder than normal.
- 3. Etiology Valvular • Congenital (BAV) • Endocarditis (acute) • Rheumatic fever (*with Mitral involvement) • Myxomatous (prolapse) • Traumatic Syphilis • Ankylosing spondylitis Root disease • Root Dilation(80% idiopathic) • Aortic dissection (acute) • Cystic medial degeneration • Marfan’s syndrome • Nonsyndromic familial aneurysm Aortitis Trauma (acute) Hypertension
- 4. Pathophysiology Incompetent closure of the aortic valve Diastolic reflux through the aortic valve can lead to left ventricular volume overload (increased preload) Increase in systolic stroke volume (due to ventricular overload) and low diastolic aortic pressure (due to aortic regurgitation) Increased SYSTOLIC and Decreased DIASTOLIC Blood Pressure WIDE PULSE PRESSURE
- 5. • The LV does not have sufficient time to dilate in response to the sudden increase in volume. • LV end-diastolic pressure increases rapidly(>40mmhg), causing an increase in pulmonary venous pressure and altering coronary flow dynamics. • Patient develops dyspnea and pulmonary edema. In severe cases, heart failure may develop. • Gradual left ventricular volume overload that leads to a series of compensatory changes, including LV enlargement and eccentric hypertrophy. • Patients may remain asymptomatic during this period. • The effective forward CO usually is normal or only slightly reduced at rest, but often it fails to rise normally during exertion. ACUTE AR CHRONIC AR
- 6. Clinical Features •(3/4)Pts with Pure/Predominant Valvular AR-Men. •Women-Primary Valvular AR who have associated rheumatic mitral valve disease In acute severe AR,LV diastolic pressure rises rapidly with associated marked elevations of LA and PA wedge pressures. •Pulmonary edema and/or cardiogenic shock may develop rapidly.
- 7. In Chronic severe AR-Long latent period, relatively asymptomatic for as long as 10–15 years. •Palpitation-early complaint.(esp. on lying) •Exertional dyspnea-symptom of diminished cardiac reserve. •Orthopnea, paroxysmal nocturnal dyspnea, and excessive diaphoresis, Anginal chest pain with severe AR.
- 8. On Physical Examination ACUTE AR •Signs of CHF or shock •Tachycardia •Peripheral vasoconstriction •Cyanosis •Pulmonary edema •*Arterial pulsus alternans CHRONIC AR •Manifestations are due to widened pulse pressure. •Diastolic pressures are often lower than 60 mm Hg, with pulse pressures often exceeding 100 mm Hg
- 9. Signs in Chronic AR •Becker sign - Visible systolic pulsations of the retinal arterioles •Corrigan’s sign - Dancing Carotids •Corrigan pulse ("water-hammer" pulse) - Abrupt distention and quick collapse on palpation of the peripheral arterial pulse •de Musset sign - Bobbing motion of the patient's head with each heartbeat •*Hill sign - Popliteal cuff systolic blood pressure 40 mm Hg higher than brachial cuff systolic blood pressure(>60-severe)
- 10. •Duroziez sign - Systolic murmur over the femoral artery with proximal compression of the artery, and diastolic murmur with distal compression. •Quincke sign - Visible pulsations of the fingernail bed with light compression of the fingernail •Traube sign ("pistol-shot" pulse) - Booming systolic and diastolic sounds auscultated over the femoral artery •Rosenbach’s sign—Pulsations of liver •Gerhardt’s sign—pulsations over enlarged spleen
- 11. PALPATION •LV impulse is Hyperdynamic & displaced *laterally and inferiorly •A diastolic thrill may be palpable along the left sternal border.
- 12. AUSCULTATION •Soft S1 (only in acute AR due to premature closure of MV) •A high frequency early decrescendo diastolic murmur in aortic area. •Duration of murmur >2/3 of diastole indicates severity. •*Austin Flint murmur
- 13. Investigations ECG • In patients with chronic severe AR, the ECG signs of LV hypertrophy become manifest. 2D Echocardiogram with Doppler • LV size is increased in chronic AR. A rapid, high-frequency diastolic fluttering of the anterior mitral leaflet produced by the impact of the regurgitant jet is a characteristic finding. Chest X-ray • The apex is displaced downward and to the left in the frontal projection. Cardiac Catheterization and Angiography • Dilated LV, Aortic Regurgitation, Dilated Aortic Root
- 14. Treatment ACUTE AR •Diuretics •IV Nitroprusside •SURGERY(recommended) *Beta-Blockers and Intra- aortic balloon counter pulsations are Contraindicated CHRONIC AR •Vasodilators- Hydralazine, DHPs, CCB •Penicillin prophylaxis in syphilitic •Beta-Blocker in Aortic root Dilation •SURGERY-Valve replacement/repair
- 15. Take Home Message. •Blood leaks across aortic valve •Primary Valve Disease OR Primary Aortic Root Disease •Increased preload, stroke volume •High Pitched Blowing Early Decrescendo diastolic murmur in 2nd Aortic area.(root dilation better heard in 1st Aortic Area). •Wide pulse pressure symptoms(>60)- Corrigan pulse and Sign •Treatment (severe disease): Surgery
- 16. THANK YOU
Editor's Notes
- *95% of cases BAV-turner and coarctation Root dilation-20%-aneurysm,syphilis,dissection
- ncreasing LV end-diastolic pressure may also lower coronary perfusion gradients, causing subendocardial and myocardial ischemia, necrosis, and apoptosis. Grossly, the LV gradually transforms from an elliptical to a spherical configuration.
- Nocturnal angina may be a particularly troublesome symptom, and it may be accompanied by marked diaphoresis. The anginal episodes can be prolonged and often do not respond satisfactorily to sublingual nitroglycerin. Systemic fluid accumulation, including congestive hepatomegaly and ankle edema, may develop late in the course of the disease.
- Nocturnal angina may be a particularly troublesome symptom, and it may be accompanied by marked diaphoresis. The anginal episodes can be prolonged and often do not respond satisfactorily to sublingual nitroglycerin. Systemic fluid accumulation, including congestive hepatomegaly and ankle edema, may develop late in the course of the disease.
- Müller sign - Visible systolic pulsations of the uvula Locomotor brachi Rosenbach-liver pulsation Gerhardts-pulsation over spleen Light house sign (alternate flushing and blanching of forehead).
- Müller sign - Visible systolic pulsations of the uvula Locomotor brachi Rosenbach-liver pulsation Gerhardts-pulsation over spleen Light house sign (alternate flushing and blanching of forehead). 14.. 15. Gerhardt’s sign—pulsations over enlarged spleen.
- when the murmur is heard best along the right sternal border, it suggests that the AR is caused by aneurysmal dilation of the aortic root A systolic ejection sound is audible in patients with BAV disease, and occasionally an s4 also may be heard. A third murmur sometimes heard in patients with severe AR is the Austin Flint murmur, a soft, low-pitched, rumbling mid-to-late diastolic murmur. It is probably produced by the diastolic displacement of the anterior leaflet of the mitral valve by the AR stream and is not associated with hemodynamically significant mitral obstruction. A mid-systolic ejection murmur is frequently audible in isolated AR. It is generally heard best at the base of the heart and is transmitted along the carotid arteries.
- when the murmur is heard best along the right sternal border, it suggests that the AR is caused by aneurysmal dilation of the aortic root A systolic ejection sound is audible in patients with BAV disease, and occasionally an s4 also may be heard. A third murmur sometimes heard in patients with severe AR is the Austin Flint murmur, a soft, low-pitched, rumbling mid-to-late diastolic murmur. It is probably produced by the diastolic displacement of the anterior leaflet of the mitral valve by the AR stream and is not associated with hemodynamically significant mitral obstruction. A mid-systolic ejection murmur is frequently audible in isolated AR. It is generally heard best at the base of the heart and is transmitted along the carotid arteries.
- ECG In patients with chronic severe AR, the ECG signs of LV hypertrophy become manifest. 2D Echocardiogram with Doppler LV size is increased in chronic AR. A rapid, high-frequency diastolic fluttering of the anterior mitral leaflet produced by the impact of the regurgitant jet is a characteristic finding. Chest X-ray The apex is displaced downward and to the left in the frontal projection. Cardiac Catheterization and Angiography Dilated LV, Aortic Regurgitation, Dilated Aortic Root
- Medical- Anti-failure, Rheumatic & IE prophylaxis, Vasodilators: ACE