Aortic Regurgitation

 

• Causes

  Chronic causes:

  • Congenital: bicuspid valve.
  • Aortic root dilatation: Marfan's, Ehlers-Danlos.
  • Inflammatory: SLE, RA or seronegative arthritis, rheumatic heart disease, Takayasu, syphilis.
  • Appetite suppressants.
  • HTN.

  Acute causes:

  • Infective endocarditis.
  • Aortic dissection.

• Signs and symptoms

  Symptoms:

  • LVF symptoms: SOB, orthopnea, PND.
  • Sense of pounding heart beat, worse on lying down or on left side.

  Signs:

  • Murmur: high-pitched (or blowing) early diastolic murmur, aortic and left sternal area. Austin Flint murmur if severe, a mid to late diastolic rumble at the apex.
  • Collapsing pulse: hyperdynamic pulse, with rapid increase then collapse. Reflects large volume pushing against little resistance through floppy valve then collapsing back down (aka 'water-hammer pulse').
  • Wide pulse pressure.
  • Hyperdynamic apex beat: forceful, displaced, diffuse i.e. >2 rib spaces.
  • Eponymous signs: visible carotid pulsation (Corrigan's sign), head nodding with beat (de Musset's sign), capillary pulsation in nail bed (Quincke's sign).

• DDx: Diastolic murmur

  • Aortic regurgitation.
  • Aortic dissection (causing aortic regurgitation).
  • Mitral stenosis.
  • Right-sided valve disease: pulmonary regurgitation, tricuspid stenosis.

• Investigations

  • Echo is diagnostic.
  • ECG: LVH.
  • CXR: LVH, dilated ascending aorta.
  • Multi-slice CT may help visualise aortic root dilation in Marfan's.

• Management

  • Manage LVF if present: ACEi (especially in HTN), β-blockers (especially in Marfan's).
  • Monitor: regular echo, 6-monthly if severe or every 2 years if mild-moderate.
  • Surgery indications: severe AR with symptoms or LVF. Threshold is lower if there is underlying disease such as Marfan's or bicuspid valve.