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Aortic Regurgitation

Title

Ñ    Aortic Regurgitation

Definition

Ñ    Incompetence of the aortic valve with regurgitation

Pathogenesis

Causes

Valve

Ñ    Infective endocarditis

Ñ    Rheumatic fever

Ñ    Prosthetic valve dysfunction

Valve Ring

Ñ    Dilatation in:

Aneurysm of the aorta

Dissecting aneurysm (type A)

Hypertension

Coarctation of the aorta

Ñ    Paraprosthetic aortic regurgitation

Septum

Ñ    Ventricular septal defect:

Loss of support for the valve

Systemic Causes

LMS

Ñ    Ankylosing spondylitis

Ñ    Other seronegative arthropathies

Ñ    Reiter’s syndrome

Ñ    Rheumatic fever

Ñ    Rheumatoid arthritis

Ñ    Marfan’s syndrome

Ñ    Hurler’s syndrome

IS

Ñ    Psoriasis

GIT

Ñ    Ulcerative colitis

RAG

Ñ    Tertiary syphilis

Pathophysiology

Ñ    Reflux of blood from the aorta into the left ventricle in diastole

Ñ    Stroke volume must increase to maintain cardiac output

Ñ    Left ventricle enlarges

Ñ    The large left ventricle is less efficient hence oxygen demand increases

Ñ    Diastolic blood pressure low due to run off of blood in diastole

Ñ    Coronary perfusion decreased

Ñ    Decreased coronary perfusion and increased oxygen demand of the ventricle results in cardiac ischaemia

Clinical Features

History

Ñ    Symptoms occur late:

After left ventricular failure develops

CVS

Ñ    Palpitations

Ñ    Angina pectoris

Ñ    Dyspnoea

Examination

CVS

Ñ    De Musset’s sign

Ñ    Muller’s sign

Ñ    Quincke’s sign

Ñ    Bounding or collapsing pulse

Ñ    Blood pressure:

 Wide pulse pressure

Ñ    Corrigan’s sign

Ñ    Apex beat:

Displaced

Thrusting in nature

Ñ    3^rd heart sound

Ñ    Blowing early diastolic murmur at the left sternal edge

Ñ    Ejection systolic flow murmur

Ñ    Austin-Flint murmur

Ñ    Pistol shot femorals

Ñ    Femoral thud

Ñ    Duroziez’s murmur

Severity of Aortic Regurgitation

Features of severe aortic regurgitation are:

Ñ    Wide pulse pressure

Ñ    Soft second heart sound

Ñ    Left ventricular 3^rd heart sound

Ñ    Short diastolic murmur

Ñ    Austin-Flint murmur

Ñ    Left ventricular failure

Investigations

Imaging

Chest X-ray 

Ñ    Left ventricular enlargement

Cardiac catheterisation

Ñ    If coronary artery disease suspected

Ñ    Severity in doubt

MRI/CT

Ñ    Assess size of aortic root

ECHO

Ñ    Dilated left ventricle

Ñ    Anatomy of the aortic valve

Ñ    Severity of aortic regurgitation

Ñ    LV function

Electrophysiology

ECG

Ñ    Left ventricular hypertrophy and strain

Management

Control

Surgery

Ñ    Aortic valve replacement

Indications for surgery

Ñ    Symptomatic patients:

·          Dyspnoea NYHA (New York Heart Association) grade II, III, IV

·          Angina

Ñ    Asymptomatic patients:

Resting LVEF (Left Ventricular Ejection Fraction) < 50%

Ñ    Patients undergoing:

·          CABG

·          Surgery on ascending aorta

·          Another valve

Ñ    Asymptomatic patients:

·          Resting LVEF >50%

·          Severe LV dilatation

End diastolic dimension > 70mm

Or

End systolic dimension > 50mm

Ñ    Patients who have aortic root disease with maximum aortic diameter:

·          ³ 45mm in patients with Marfan’s syndrome

·          ³ 50mm for patients with bicuspid valves

·          ³ 55mm for other patients

Drugs

Ñ    Treat heart failure

Ñ    Control arrhythmia

Prevention

Ñ    Endocarditis prophylaxis

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