Aortic Regurgitation

Aka: Aortic Regurgitation, Aortic Insufficiency

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II. Pathophysiology

  1. Cardiovascular effects of chronic Aortic Regurgitation
    1. Increased Stroke Volume
    2. Systolic Hypertension
    3. High Pulse Pressure (due to low diastolic pressure)
    4. Increased Afterload
  2. Outcome
    1. Left ventricular dilatation and hypertrophy
    2. Left Ventricular Failure
    3. Increased myocardial oxygen demand

III. Causes: Chronic

  1. Rheumatic Heart Disease (Rheumatic Fever)
  2. Congenital Heart Disease (e.g. bicuspid aortic valve)
  3. Aneurysm of Valsalva's sinus
  4. Aortitis (e.g. Syphilis)
  5. Weight Loss Medications (e.g. Dexfenfluramine)
  6. Collagen Vascular Disease or Connective Tissue Disease
    1. Systemic Lupus Erythematosus
    2. Marfan's Syndrome
    3. Turner's Syndrome
    4. Pseudoxanthoma elasticum
    5. Ankylosing Spondylitis
    6. Ehlers-Danlos Syndrome
    7. Polymyalgia Rheumatica

IV. Causes: Acute

  1. Bacterial Endocarditis or other valvular infection
  2. Aortic Dissection
  3. Chest Trauma
  4. Myxomatous aortic valve

V. Predisposing Factors

  1. Bicuspid aortic valve

VI. Symptoms

  1. Asymptomatic until severe Left Ventricular Failure
  2. Initial
    1. Decreased functional capacity
    2. Weakness or Fatigue
  3. Left Ventricular Failure symptoms
    1. Dyspnea on exertion
    2. Orthopnea
    3. Anginal pain

VII. Signs

  1. Early Diastolic Murmur
    1. Characteristics
      1. Initial: High-pitched blowing decrescendo murmur
      2. Later: Lower pitched, loud, and throughout diastole
    2. Murmur localizes to sternal border
      1. Right second interspace
      2. Left third interspace
  2. Accentuated systolic activity
    1. Accentuated precordial thrust at the apex
    2. Accentuated A2 heart sound
  3. Wide Pulse Pressure
    1. High systolic Blood Pressure due to increase Stroke Volume
    2. Low diastolic pressure from aortic run-off
    3. Collapsing Pulse (Water-Hammer Pulse)
      1. Rapid systolic upstroke and rapid diastolic downstroke
  4. Large Artery Findings
    1. Pistol-Shot Sound (femoral artery or Carotid Artery)
      1. Loud, booming sound with systole when auscultating femoral artery
    2. Duroziez's Sign (femoral artery)
      1. Auscultation of femoral artery
      2. Systolic Murmur when femoral artery compressed proximally
      3. Diastolic Murmur when femoral artery compressed distally
    3. Corrigan's Pulse (Carotid Artery)
      1. Jerky Carotid Artery pulse (strong onset that rapidly diminishes)
    4. Pulsus Bisferiens (Carotid Artery)
      1. Double peak pulse (two peaks in systole) seen in severe Aortic Regurgitation
  5. Synchronous Body Movements with Cardiac Cycle
    1. Musset's Sign or DeMusset's Sign
      1. Head nodding (anterior-posterior) in rhythm with pulse
    2. Landolfi's Sign
      1. Alternating Pupil Dilation and constriction with Cardiac Cycle
    3. Becker Sign
      1. Accentuated Retinal artery pulsations
    4. Muller's Sign
      1. Uvula pulsations
    5. Lighthouse Sign
      1. Alternating forehead and face blanching and Flushing
    6. Quincke's Pulse
      1. Gentle pressure at nail bed applied
      2. Nail bed alternates between blanching and erythema
    7. Abdominal Organ Pulsations
      1. Rosenbach's Sign (liver pulsations)
      2. Gerhardt's Sign (enlarged Spleen pulsations)
  6. Hill's Sign
    1. Popliteal systolic pressure > brachial systolic pressure (>20 mmHg)
    2. Interpretation: Mild AR >20 mmHg, moderate AR >40 mmHg, severe AR >60 mmHg
  7. Mayne's sign
    1. Listed for historical purpose only
    2. Diastolic BP drops more than 15 mmHg with arm raised
    3. Not pathognomonic for Aortic Insufficiency
    4. Abbas (1987) South Med J 80:1051-2 [PubMed]

VIII. Imaging: Echocardiogram

  1. Small regurgitant aortic jet may be normal
  2. Assess aortic valve morphology
  3. Assess aortic root size
  4. Estimate Aortic Regurgitation severity
  5. Assess left ventricular size and function
    1. Left ventricular dilatation
    2. Left Ventricular ejection fraction

IX. Monitoring

  1. Echocardiogram yearly or earlier for change in symptoms

X. Management

  1. SBE Prophylaxis
  2. Medical therapy: Afterload reduction with vasodilators
    1. May delay surgical intervention 2 to 3 years
    2. Agents
      1. Nifedipine (Procardia)
      2. Hydralazine (Apresoline)
      3. ACE Inhibitor

XI. Management: Aortic Valve Replacement

  1. General
    1. Early surgical intervention results in better outcome
    2. Goals of surgical intervention
      1. Symptoms more than mild
      2. Keep Ejection fraction >55%
      3. Keep end systolic dimension <55 mm
  2. Class I AHA Indications for Aortic Valve Replacement
    1. NYHA Class III or IV Heart Failure symptoms
    2. NYHA Class II Symptoms with LVEF >50%, but decline
      1. Progressive LV dilatation
      2. Decreasing LV ejection fraction on serial echo
      3. Decreasing Exercise tolerance on stress testing
    3. Canadian Heart Association Class II Angina
    4. Mild to moderate LV dysfunction (LVEF 25 to 49%)
    5. Moderate to severe Aortic Regurgitation and Pre-op
      1. Coronary Artery Bypass Graft
      2. Other valvular surgery
  3. Class IIA AHA Indications for Aortic Valve Replacement
    1. NYHA Class II Symptoms with stable LVEF >50%
    2. Severe left ventricular dilatation
      1. End diastolic diameter >75 mm
      2. End systolic diameter >55 mm
  4. Class IIB AHA Indications for Aortic Valve Replacement
    1. Severe Left Ventricular Dysfunction (LVEF <25%)
    2. Moderate and progressive left ventricular dilatation
      1. End diastolic diameter 70 to 75 mm
      2. End systolic diameter 50 to 55 mm

XII. Course of Chronic Aortic Regurgitation

  1. Asymptomatic with LV Ejection Fraction >50%
    1. Progression to symptoms: <6% per year
    2. Progression to LV Dysfunction: <3.5% per year
    3. Sudden death risk: 0.2% per year
  2. Asymptomatic with LV Ejection Fraction <50%
    1. Progression to symptoms: >25% per year
  3. Symptomatic with LV Ejection Fraction <50%
    1. Mortality: 10% per year

XIII. References

  1. Kondos (1998) CMEA Medicine Review Lecture, San Diego
  2. Assi (1998) Postgrad Med 104(6):99-110
  3. Bonow (1998) Circulation 98:1949-84 [PubMed]
  4. Carabello (1997) N Engl J Med 337(1):32-41 [PubMed]
  5. Cheitlin (2001) Am Fam Physician 64(10):1709-14 [PubMed]
  6. Shipton (2001) Am Fam Physician 63(11):2201-8 [PubMed]

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Related Studies

Ontology: Aortic Valve Insufficiency (C0003504)

Definition (CHV) Backflow of blood from the aorta into the left ventricle, due to imperfect functioning of the aortic valve
Definition (CHV) Backflow of blood from the aorta into the left ventricle, due to imperfect functioning of the aortic valve
Definition (CHV) Backflow of blood from the aorta into the left ventricle, due to imperfect functioning of the aortic valve
Definition (CHV) Backflow of blood from the aorta into the left ventricle, due to imperfect functioning of the aortic valve
Definition (CHV) Backflow of blood from the aorta into the left ventricle, due to imperfect functioning of the aortic valve
Definition (CHV) Backflow of blood from the aorta into the left ventricle, due to imperfect functioning of the aortic valve
Definition (CHV) Backflow of blood from the aorta into the left ventricle, due to imperfect functioning of the aortic valve
Definition (NCI) The backward flow of blood from the aorta into the left ventricle, owing to insufficiency of the aortic semilunar valve; it may be chronic or acute.
Definition (NCI) Dysfunction of the aortic valve characterized by incomplete valve closure.
Definition (NCI_FDA) The backward flow of blood from the aorta into the left ventricle, owing to insufficiency of the aortic semilunar valve; it may be chronic or acute.
Definition (CSP) backflow of blood from the aorta into the left ventricle, owing to imperfect functioning of the aortic semilunar valve.
Definition (MSH) Pathological condition characterized by the backflow of blood from the ASCENDING AORTA back into the LEFT VENTRICLE, leading to regurgitation. It is caused by diseases of the AORTIC VALVE or its surrounding tissue (aortic root).
Concepts Disease or Syndrome (T047)
MSH D001022
ICD10 I35.1
SnomedCT 60234000
English Aortic Incompetence, Aortic Valve Incompetence, Regurgitation, Aortic Valve, Aortic Regurgitation, Incompetence, Aortic, Incompetence, Aortic Valve, Insufficiency, Aortic Valve, Regurgitation, Aortic, Aortic (valve) insufficiency, AR, AORTIC VALVE INCOMPETENCE, AORTIC INCOMPETENCE, aortic regurgitation, aortic regurgitation (diagnosis), Aortic Valve Insufficiency [Disease/Finding], Incompetence;aortic, Regurgitation;aortic, aortic insufficiency, ai, aortic valve incompetence, aortic valve regurgitation, aortic valve insufficiency, Aortic Insufficiency, Aortic Valve Regurgitation, AORTIC REGURGITATION, AORTIC INSUFFICIENCY, Aortic insufficiency, Aortic incompetence, Aortic regurgitation, Aortic valve insufficiency, AI - Aortic incompetence, AR - Aortic regurgitation, Aortic valve incompetence, Aortic valve regurgitation (disorder), Aortic valve regurgitation, insufficiency; aortic, aorta; insufficiency, aortic valve; insufficiency, aortic valve; regurgitation, Aortic valve incompetence, NOS, Aortic valve insufficiency, NOS, Aortic valve regurgitation, NOS, Aortic regurgitation, NOS, Aortic Valve Insufficiency, incompetency; aortic valve, aorta; incompetency, aortic valve; incompetency, aortic incompetence
French INSUFFISANCE AORTIQUE, Insuffisance de valve aortique, Insuffisance valvulaire aortique, Régurgitation aortique, Insuffisance aortique, Insuffisance de la valve aortique
Italian Incompetenza della valvola aortica, Insufficienza valvolare aortica, Rigurgito aortico, Incompetenza aortica, Insufficienza aortica
Dutch aortaregurgitatie, aortaklepinsufficiëntie, aorta-incomptetentie, aorta; insufficiëntie, aortaklep; insufficiëntie, aortaklep; regurgitatie, insufficiëntie; aorta, Aorta(klep)insufficiëntie, aortaklepincompetentie, aorta; incompetentie, aortaklep; incompetentie, incompetentie; aortaklep, Aortaklepincompetentie, Aortaregurgitatie, Aortainsufficiëntie, Aortaklepinsufficiëntie, Insufficiëntie, aortaklep-
Portuguese Insuficiência aórtica, Regurgitação aórtica, Incompetência Aórtica, INSUFICIENCIA AORTICA, INSUFICIENCIA VALVULAR AORTICA, Insuficiência da válvula aórtica, Incompetência da Valva Aórtica, Insuficiência da Valva Aórtica, Regurgitação Aórtica
Spanish Insuficiencia de válvula aórtica, Imcompetencia aórtica, Regurgitación aórtica, Insuficiencia Aortica, incompetencia de válvula aórtica, insuficiencia valvular aórtica (trastorno), insuficiencia valvular aórtica, Insuficiencia de la válvula aórtica, Incompetencia Aórtica, Incompetencia de la Válvula Aórtica, Insuficiencia de la Válvula Aórtica, Regurgitación Aórtica
Swedish Aortaklaffinsufficiens
Japanese ﾀﾞｲﾄﾞｳﾐｬｸﾍﾞﾝﾍｲｻﾌｾﾞﾝｼｮｳ, ﾀﾞｲﾄﾞｳﾐｬｸﾍﾞﾝｷﾞｬｸﾘｭｳｼｮｳ, ﾀﾞｲﾄﾞｳﾐｬｸﾍﾞﾝﾍｲｻﾌｾﾞﾝ, 大動脈弁閉鎖不全症, 大動脈弁逆流症, 大動脈弁閉鎖不全
Finnish Aorttaläpän vuoto
Russian AORTAL'NOGO KLAPANA NEDOSTATOCHNOST', REGURGITATSIIA AORTAL'NAIA, AORTAL'NAIA NEDOSTATOCHNOST', АОРТАЛЬНАЯ НЕДОСТАТОЧНОСТЬ, АОРТАЛЬНОГО КЛАПАНА НЕДОСТАТОЧНОСТЬ, РЕГУРГИТАЦИЯ АОРТАЛЬНАЯ
Czech Aortální inkompetence, Aortální regurgitace, Inkompetence aortální chlopně, Insuficience aortální chlopně, aortální chlopeň - insuficience, aortální regurgitace
Korean 대동맥(판) 폐쇄부
Croatian AORTNI ZALISTAK, INSUFICIJENCIJA, INSUFICIJENCIJA AORTNOG OTVORA, INSUFIJENCIJA AORTNOG ZALISKA
Polish Niedomykalność zastawki aorty, Niedomykalność aortalna
Hungarian Aorta billenytyű elégtelenség, Aorta billentyű elégtelenség, Aorta regurgitácó
Norwegian Aortainsuffisiens
German Aorteninsuffizienz, Aortenklappeninsuffizienz, Aortenklappenregurgitation, Aortenregurgitation, Insuffizienz, Aortenklappen-
Derived from the NIH UMLS (Unified Medical Language System)

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