Aortic regurgitation

The name originated from a Victorian toy, consisted of a sealed tube, half filled with water and half being vacuum. Inversion of the tube causes the fluid to fall rapidly without air resistance and strike the end like hammer blow.

See more about pulse at Examination of cardiovascular system

* Long Cases in Clinical Medicine, ABM Abdullah Page: 191

In collapsing pulse, there is rapid upstroke and descent of pulse, seen by raising the arm above the head.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 191

Collapsing pulse is always high volume, but all high volume pulse are not collapsing.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 191

Congenital

• Bicuspid valve or disproportionate cusps

Acquired

• Rheumatic disease
• Infective endocarditis
• Trauma
• Aortic dilatation (Marfan’s syndrome, aneurysm, dissection, syphilis, ankylosing spondylitis)

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 623

As follows:

• Chronic rheumatic heart disease
• Bicuspid aortic valve
• Hypertension (by aortic dilatation)
• Seronegative arthritis (ankylosing spondylitis, Reiter’s syndrome, psoriatic arthropathy)
• Rheumatoid arthritis
• SLE
• Marfan’s syndrome

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 49

As follows:

• Acute bacterial endocarditis.
• Acute rheumatic fever (due to vulvulitis)
• Dissecting aneurysm affecting ascending aorta
• Ruptured sinus of Valsalva

Note:

In acute AR, there is soft, short, early diastolic murmur with diastolic thrill. Most patients have heart failure. Peripheral signs and cardiomegaly are absent. It should be treated by emergency surgery.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 49; Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 86

See details about pulse at Examination of cardiovascular system

As follows:

• AR
• PDA
• A-V fistula
• Hyperdynamic circulation (thyrotoxicosis, anemia, beriberi, pregnancy).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 192

As follows:

• Aortic regurgitation
• Pulmonary regurgitation (evidence of pulmonary hypertension is present and other peripheralsigns of AR are absent).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 192

Due to increased flow through aortic valve without aortic stenosis (or may be associated with AS).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 192

No, ESM in this patient is associated with thrill and does not radiate to neck.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 49

Yes, it is called Austin Flint murmur.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 49

It is due to regurgitant flow from aortic valve causing vibration of the anterior leaflet of mitral valve.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 192

In MS, following features are present along with MDM

• Tapping apex beat
• Loud first heart sound
• Opening snap
• MDM is associated with presystolic accentuation.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 49

• Coronary perfusion occurs during diastole. In aortic regurgitation, there is lowering of diastolic blood pressure, thereby coronary perfusion pressure is compromised, hence angina occurs.
• Marked compensatory left ventricular hypertrophy may result in angina.

*Short and Long Cases in Clinical Medicine, HN Sarker Page: 50; Long Cases in Clinical Medicine, ABM Abdullah Page: 195

Symptoms

• Mild to moderate aortic regurgitation
  • Often asymptomatic
  • Awareness of heart beat, ‘palpitations’
• Severe aortic regurgitation
  • Breathlessness
  • Angina

Signs

• Pulses
  • Large-volume or ‘collapsing’ pulse
  • Low diastolic and increased pulse pressure
  • Bounding peripheral pulses
  • Capillary pulsation in nail beds: Quincke’s sign
  • Femoral bruit (‘pistol shot’): Duroziez’s sign
  • Head nodding with pulse: de Musset’s sign
• Murmurs
  • Early diastolic murmur
  • Systolic murmur (increased stroke volume)
  • Austin Flint murmur (soft mid-diastolic)
• Other signs
  • Displaced, heaving apex beat (volume overload)
  • Pre-systolic impulse
  • Fourth heart sound
  • Crepitations (pulmonary venous congestion)

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 623

• Pulse: 92/min, high volume, collapsing type, normal in rhythm.
• JVP: Normal.
• There is dancing carotid pulse in the neck (Corrigan sign).
• BP: 180/55 mmHg (high systolic, low diastolic and wide pulse pressure).

On inspection:

• Visible cardiac impulse (may or may not be).

On palpation:

• Apex beat: In left … intercostal space, … cm from midline, thrusting in nature.
• Thrill: Present in left parasternal area, diastolic in nature (patient sitting and bending forward).

On auscultation:

• First heart sound: Normal in all the areas.
• Second heart sound: A2 is absent and P2 is normal.
• There is an EDM which is high pitched, blowing, best heard in left lower parasternal area in third or fourth intercostal space, with patient bending forward and breathing held after expiration.

* Short Cases in Clinical Medicine, ABM Abdullah, 5th Edition Page: 84

As follows:

• Quinke’s sign:  capillary pulsation at the nail bed (alternate flushing and paleness of skin at the root of the nail while pressure is applied at the tip of the nail). It may be normally present andbetter seen with glass slide.
• de Musset’s sign:  head nodding with heart beat (with each pulse).
• Duroziez’s sign:  usually diastolic (may be systolic) murmur over the femoral artery on gradual compression of the vessel and ausculted proximally.
• Pistol shot: may be heard over femoral artery (Traube’s sign).
• Hill’s sign:  high BP in legs than arms (high systolic BP, 60 mm difference) indicates severe AR.
• Mueller’s sign:  pulsation in uvula with heart beat.

Note

Most of the signs are rare and unhelpful.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 191

The typical signs of AR:

• Pulse—High volume collapsing pulse
• BP—High systolic, low diastolic, and wide pulse pressure
• Thursting apex beat
• Early diastolic murmur on auscultation best heard in left parasternal area in sitting position breath-holding after expiration.

Pre-exam preparation for medicine, HN Sarker

Following signs are to be looked for

• Evidence of ankylosing spondylitis, e. g. question mark posture
• Evidence of rheumatoid arthritis, e. g. Rheumatoid hands
• Evidence of Marfan’s syndrome, e. g. Tall stature, high-arched palate, dislocated lens, and iridodonesis
• Eye-Argyll Robertson pupil (syphilis).

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 49

As follows:

• Eye: Argyll Robertson pupil (may be present in neurosyphilis), dislocated lens, irregular pupils, iridodonesis (found in Marfan’s syndrome).
• Mouth:  high arched palate (Marfan’s syndrome).

Note

Also look for evidence of ankylosing spondylitis, rheumatoid arthritis which may cause aortic regurgitation.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 192

Signs of severe AR:

• Wide pulse pressure
• Prolonged EDM
• A2 absent
• Presence of left ventricular 3rd heart sound
• Presence of Austin Flint murmur
• Signs of LVF
• Signs of enlarging heart
• Signs of pulmonary hypertension

* Long Cases in Clinical Medicine, ABM Abdullah Page: 193; Short and Long Cases in Clinical Medicine, HN Sarker Page: 49

ECG

• Initially normal, later left ventricular hypertrophy and T-wave inversion

Chest X-ray

• Cardiac dilatation, maybe aortic dilatation
• Features of left heart failure

Echo

• Dilated LV
• Hyperdynamic LV
• Doppler detects reflux
• Fluttering anterior mitral leaflet

Cardiac catheterisation (may not be required)

• Dilated LV
• Aortic regurgitation
• Dilated aortic root

Other investigations to find out the cause according to the clinical suspicion.

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 624; Long Cases in Clinical Medicine, ABM Abdullah Page: 191

Initially normal, later left ventricular hypertrophy and T-wave inversion.

* Davidson’s Principles and Practice of Medicine, 22nd Edition Page: 624

X-ray chest may show following changes:

• Cardiomegaly
• Pulmonary congestion
• Prominent pulmonary arteries (pulmonary hypertension)
• Aortic valve calcification.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 49

The role of echocardiography in AR is:

• Can assess valve morphology (bicuspid or tricuspid valve)
• Can measure aortic cusp separation
• Can assess aortic root size and dilatation
• Can establish aetiology of aortic regurgitation
• Can determine severity of aortic regurgitation
• Can assess left ventricular size (in particular left ventricular end-systolic diameter)
• Can assess left ventricular systolic function.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 49

Echocardiography, preferably color Doppler.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 191

Because:

• Pulse is high volume and collapsing
• Dancing carotid pulse
• High systolic and low diastolic BP (wide pulse pressure)
• Presence of EDM in the left lower parasternal area.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 191

Pulmonary regurgitation (PR).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 191

In PR, findings are:

• Early diastolic murmur in pulmonary area (called Graham Steel murmur), which is more prominent on inspiration.
• Evidence of pulmonary hypertension may be present (e.g. palpable P2 , left parasternal heave, epigastric pulsation, etc.).

Note

Pulmonary regurgitation is rare as an isolated phenomenon, usually associated with pulmonary artery dilatation due to pulmonary hypertension, secondary to other diseases (e.g. mitral stenosis).

* Long Cases in Clinical Medicine, ABM Abdullah Page: 191

In AR of rheumatic origin:

• Positive history of rheumatic fever
• May be associated with other valvular lesion, e. g. commonly mitral valve
• Echocardiogram – there should be thickening and shortening of cusps, fusion of commissure. (If AR is due to other cause: there is dilatation of aorta or valve ring).

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 49; Long Cases in Clinical Medicine, ABM Abdullah Page: 194

Note

Syphilis never causes AS, only AR.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 194

As follows:

1. In asymptomatic moderate to severe AR with normal LV function:
   • Prophylaxis for infective endocarditis
   • Regular follow-up with echocardiogram to assess left ventricular function and left ventricular end-systolic diameter
2. Symptomatic patient:
   • Medical therapy: With diuretic, vasodilators like nifedipine, ACE inhibitor and treatment of primary cause.
   • Surgical therapy:  Valve replacement.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 50

• To exclude coronary artery disease as a cause for symptoms
• All patients having aortic valve replacement should have coronary angiography to exclude significant coronary stenosis that would require bypass grafting at the time of valve replacement
• An aortogram can provide information on the degree of regurgitation and assess aortic root size.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 50

• Symptomatic patients
  • Severe aortic regurgitation with heart failure
  • Severe aortic regurgitation with angina.
• Asymptomatic patients
  • Left ventricular dilatation (left ventricular end systolic diameter >55 mm or end diastolic diameter >75 mm)
  • Left ventricular systolic dysfunction (ejection fraction <50%)
  • Aortic root dilatation >50 mm (irrespective of the degree of aortic regurgitation).

Note:

The valve should be replaced before significant left ventricular dysfunction occurs.

* Short and Long Cases in Clinical Medicine, HN Sarker Page: 50

As follows:

• Acute LVF
• Infective endocarditis
• Arrhythmia

* Long Cases in Clinical Medicine, ABM Abdullah Page: 194

To diagnose AR, remember the formula of 3:

• 3 pulse: collapsing (water hammer), dancing carotid and capillary pulsation.
• 3 BP: rise of systolic, fall of diastolic and wide pulse pressure.
• 3 murmur: early diastolic murmur, Austin Flint murmur and ejection systolic murmur.

* Long Cases in Clinical Medicine, ABM Abdullah Page: 192