Aortic Regurgitation

Aortic regurgitation or Aortic insufficiency is a leaking of the aortic valve causing back flow of blood from the aorta to the left ventricle consequently resulting the left ventricle to work harder to maintain cardiac output.

Acute causes: infective endocarditis, ascending aorta dissection, trauma
Chronic causes: Connective tissue disease (Marfans, Ehlers-Danlos), congenital, rheumatic fever, Takayasu arteritis, rheumatoid arthritis, seronegative arthritides, hypertension, syphilitic arotitis, SLE

The most common cause in the developed world is annuloaortic ectasia (aortic dilatation), which is idiopathic in the majority of cases

Presentation

Similar features to heart failure

Exertional Dyspnoea is the most common presenting feature
Orthopnoea, paroxysmal nocturnal dyspnoea, palpitations, angina and syncope
Cyanosis may occur in acute cases

History

Duration and type of symptoms
Chest pain - angina history
Syncope - frequency, associated features, warning signs, postal hypotension, movement
Dyspnoea - Dyspnoea - onset, aggravating and relieving factors. Exercise tolerance.
Does the patient have any risk factors for developing vascular disease - Hypertension, hypercholesterolaemia, obesity, diabetes, previous acute coronary event/stroke, smoker, lifestyle/occupation, family history of ischaemic heart disease?
Childhood infections - rheumatic fever
PMHx - previous MI, COPD, pneumonia, valvular disease as a child, arthritis, syphilis infection
FH - history of congenital tissue disease, autoimmune disease, arthritis

Vital signs / observations

May be cyanotic in acute presentation

Examination

Collapsing (water-hammer) pulse with a wide pulse pressure. displaced and hyper dynamic apex beat

High pitch early diastolic murmur (heard best in expiration, with the patient sitting forward)

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Corona's sign - carotid pulsation
de Musset's sign - head nodding with each heart beat
Quincke's sign - capillary pulsations in nail beds
Duroziez's sign - in the groin, a finger compressing the femoral artery 2cm proximal to the stethoscope gives a systolic murmur; if 2cm distal it gives diastolic murmur as blood flows backwards
Traube's sign - "pistol shot" sound over the femoral arteries
Austin Flint murmur indicates severe aortic disease - this is a mid-diastolic murmur cause by fluttering of the anterior mitral valve cusp caused by the regurgitant stream

Bedside test

ECG - Typically left ventricular hypertrophy. Left axis deviation.

Laboratory investigations

FBC - anaemia may worsen symptoms

Radiological investigations

CXR - cardiomegaly and LVH. Mediastinal dilatation commonly found.
Transthoracic Echocardiogram - diagnostic and doppler may determine the gradient across the valves.

Cardiac catheterisation

This can assess the valve gradient, LV function and coronary artery disease
Risk of emboli with investigation

Management

The main goal of medical treatment is to reduce systolic hypertension in an attempt to decrease after load. Trials have found benefit from ACE-i, hydrazine and nifedipine.

Surgical

Surgical treatment is indicated if increasing symptoms, enlarging heart on echo and ECG deterioration. It is also indicated if LV function <50% in asymptomatic patients however the aim is to prevent LV dysfunction as early as possible.

Surgical management involves an aortic valve replacement

Follow up

Complications

Prognosis

Predictors of poor prognostic survival include ejective fraction <50%, NYHA III or IV, duration of CCF >12 months.

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