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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