History

Fact Explanation
Asymptomatic Patients with mild to moderate Aortic Regurgitation (AR) might be asymptomatic and may remain asymptomatic for many years. When the compensatory ventricular dilatation and hypertrophy is no longer effective in maintaining the adequate cardiac output, symptoms begin to appear. [1,2]
Palpitations In mild to moderate AR palpitations occur when lying on the left side, due to the increased stroke volume. [3]
Angina The coronary perfusion pressure (difference between the aortic diastolic pressure and the right atrial pressure) is reduced with the reduced diastolic blood pressure. Hence myocardial ischemia develops. Another reason is the increased demand of oxygen by the hypertrophied left ventricle. [2]
Features of Heart Failure (HF) Eg: Paroxysmal nocturnal dyspnea, peripheral edema, orthopnea, breathlessness on exertion, angina on exertion. At one point the compensatory left ventricular hypertrophy fails to maintain the adequate cardiac output. This results in systolic heart failure. [3]
Acute onset and rapidly developing symptoms of HF. Acute HF results due to acute AR. Conditions like aortic dissection, ruptured sinus of Valsalva aneurysm, and failure of prosthetic valve can result in acute AR. [3] With above acute conditions cardiac muscles are unable to dilate the left ventricle. So according to the Frank-Starling law the force of contraction can not be increased. This results in a decreased stroke volume. [1] If the patient has aortic dissection he might complain of an abrupt onset of severe chest, back, or abdominal pain, which is tearing in quality. [4]
History of Rheumatic fever Rheumatic fever affects the mitral valve followed by the aortic valve. Rheumatic fever is the commonest cause of acquired AR in developing countries, whereas in the western countries degenerative diseases and congenital causes predominate. [5]
History of Infective Endocarditis (IE) In most patients IE, affects the mitral and aortic valves. AR might develop as a consequence of IE as well. [6]
History of syphilis Cardiovascular syphilis, results in aortitis. This might result in various complications like stenosis of the coronary orifices, aneurysms and aortic regurgitation. [7]
History of severe hypertension Chronic AR can result due to severe hypertension. [8]
Incidental finding in patients with Reiter’s syndrome, Ankylosing spondylitis, Rheumatoid arthritis and osteogenesis imperfecta. Those conditions are known to be associated with AR. Patients presenting with those conditions might be found to have AR. [3]
References
  1. Guidelines for the Management of Patients With Valvular Heart Disease. Circulation.1998; 98: 1949-1984. http://circ.ahajournals.org/content/98/18/1949.long
  2. MELVIN D. CHEITLIN. Surgery for Chronic Aortic Regurgitation: When Should It Be Considered? Am Fam Physician. 2001 Nov 15;64(10):1709-1716.
  3. PARVEEN KUMAR, MICHAEL CLARK. Kumar and Clerk’s Clinical Medicine. 7th ed. London: Elsevier Limited, 2009
  4. DEREK JUANG, ALAN C. BRAVERMAN, KIM EAGLE. Aortic Dissection. circulation.2008; 118: e507-e510 http://circ.ahajournals.org/content/118/14/e507.full
  5. GERALD MAURER. Aortic regurgitation. Heart 2006;92:994-1000. http://heart.bmj.com/content/92/7/994
  6. ASHLEY EA, NIEBAUER J: Cardiology Explained. London: Remedica; 2004. http://www.ncbi.nlm.nih.gov/books/NBK2208/
  7. KAMPMEIER R.H, HUGH J. MORGAN. The Specific Treatment of Syphilitic Aortitis. Circulation. 1952;5:771-778
  8. MICHAEL KIM, MARY J. ROMAN, M. CHIARA CAVALLINI, JOSEPH E. SCHWARTZ,THOMAS G. PICKERING, RICHARD B. DEVEREUX. Effect of Hypertension on Aortic Root Size and Prevalence of Aortic Regurgitation. Hypertension.1996; 28: 47-52. https://hyper.ahajournals.org/content/28/1/47.full

Examination

Fact Explanation
Large-volume pulse or collapsing pulse. The left ventricle hypertrophies and later dilates to increase the cardiac output. The stroke volume may eventually be increased. [1] This results in large volume pulses. But as the AR worsens large volume of blood regurgitates and this results in a rapid back flow of blood from the aorta. This results in collapsing pulse.
Low diastolic blood pressure Due to the large volume of blood that regurgitates back to the left ventricle during the diastole, the diastolic pressure drops significantly.
Increased pulse pressure Pulse pressure is the difference between the systolic and the diastolic blood pressure. Since the diastolic blood pressure is lower than the normal the pulse pressure rises. [2]
Quincke's sign This is the nail bed capillary pulsations, which can be seen with compression of the nail bed with a glass slide. [3]
Duroziez's sign (Traube’s sign) Also known as 'pistol shot' femorals. This sign occurs due to the forward and backward flow of the blood in the femoral arteries. Once the stethoscope is placed over the femoral artery and pressure is applied distally, a bruit can be heard. If found, it is a sign of severe AR. [2]
De Musset's sign Head nodding with each pulse. [3]
Corrigan’s pulse This sign is the visible carotid pulsations. [3]
Muller’s sign This is the pulsations of the uvula. [3]
Displaced and forceful apex beat The left ventricle hypertrophies and the apex beat becomes forceful in quality. [4,5] Due to the continuous volume overload the left ventricle enlarges and deviates the apex laterally and inferiorly. [3]
Early diastolic murmur A high-pitched early diastolic murmur is best heard at the left sternal edge in the fourth intercostal space with the patient leaning forward and the breath held in expiration. [2]
Austin Flint murmur (soft and mid systolic murmur) The regurgitant jet of blood causes partial closure and vibration of the anterior mitral leaflet. This may produce effects similar to mitral stenosis leading to a soft mid-diastolic (Austin Flint) murmur. [6]
Systolic murmur A systolic flow murmur can be auscultated over the aortic area of the precordium. This is due to the increased flow of blood through the aortic valve. [3]
Features of left heart failure With acute aortic regurgitation pulmonary crepitations and/or cardiogenic shock will be seen. [7]
Becker sign Visible systolic pulsations of the retinal arterioles
Hill sign Systolic blood pressure measured in the popliteal cuff is 40 mm Hg higher than the systolic blood pressure measured at the brachial cuff.
References
  1. GERALD MAURER. Aortic regurgitation. Heart 2006;92:994-1000. http://heart.bmj.com/content/92/7/994
  2. PARVEEN KUMAR, MICHAEL CLARK: Kumar and Clerk’s Clinical Medicine. 7th ed. London: Elsevier Limited, 2009
  3. RAFFI BEKEREDJIAN, PAUL A. GRARBURN, Aortic Regurgitation. Circulation. 2005; 112: 125-134. http://circ.ahajournals.org/content/112/1/125.full#ref-30
  4. RICCI DR. Afterload mismatch and preload reserve in chronic aortic regurgitation. Circulation. 1982; 66: 826–834.
  5. MAGID NM, YOUNG MS, WALLERSON DC, GOLDWEIT RS, CARTER JN, DEVEREUX RB, BORER JS. Hypertrophic and functional response to experimental chronic aortic regurgitation. J Mol Cell Cardiol. 1988; 20: 239–246.
  6. RAHKO PS. Doppler and echocardiographic characteristics of patients having an Austin Flint murmur. Circulation. 1991; 83: 1940–1950.
  7. Guidelines for the Management of Patients With Valvular Heart Disease. Circulation.1998; 98: 1949-1984. http://circ.ahajournals.org/content/98/18/1949.long

Differential Diagnoses

Fact Explanation
Thyrotoxicosis Thyrotoxicosis is a hyperdynamic state and it can result in collapsing pulse and aortic flow murmur.
Severe anemia Severe anemia also causes a hyperdynamic state. So aortic flow murmur and collapsing pulse will be detected. But the other signs of AR might not be there.
Pregnancy Similar to above two conditions.
Acute Coronary Syndrome Angina might mimic an acute coronary syndrome.
Heart Failure Acute AR and acute left heart failure are similar clinical presentations. Predisposing conditions of acute AR should be asked in the history in order to differentiate the two.
Infective Endocarditis (IE) Features of inflammation like fever and other signs of IE will aid in differentiating the two. Transesophageal echo will further narrow down the diagnosis of IE. [1]
Arteriovenous fistula (AVF) Large extra cardiac left to right shunts which occur due to AVF Eg: patent ductus arteriosus,peripheral arteriovenous malformations, also create collapsing pulse and might predispose heart failure.
References
  1. ASHLEY EA, NIEBAUER J: Cardiology Explained. London: Remedica; 2004.

Investigations - for Diagnosis

Fact Explanation
Electrocardiogram (ECG) ECG is initially normal, later LV hypertrophy develops. T-wave inversion indicating the left ventricular strain pattern can be seen later. Normally, sinus rhythm is present. [1]
Chest X-Ray (CXR) As the disease progresses cardiac dilatation and sometimes aortic dilatation can be seen in the CXR. Features of left heart failure like, pulmonary edema, Kerly B lines, cardiomegaly can also be seen. The ascending aortic wall may be calcified in syphilis, and the aortic valve may be calcified if valvular disease is responsible for the regurgitation. [1]
2D echocardiogram The left ventricle is dilated and hyperdynamic. Fluttering of the anterior mitral leaflet. Doppler studies can detect the re flux of blood and the severity of the AR. [2] Also 2D echo can estimate the degree of pulmonary hypertension. [2]
Cardiac catheterization Although not compulsory cardiac catheterization can demonstrate the dilated left ventricle, aortic regurgitation and the dilated aortic root. [1]
Magnetic Resonance Imaging. (MRI) MRI is particularly useful in assessing the degree and extent of aortic dilatation. [1,3]
References
  1. PARVEEN KUMAR, MICHAEL CLARK: Kumar and Clerk’s Clinical Medicine. 7th ed. London: Elsevier Limited, 2009
  2. Guidelines for the Management of Patients With Valvular Heart Disease. Circulation.1998; 98: 1949-1984. http://circ.ahajournals.org/content/98/18/1949.long
  3. CHATZIMAVROUDIS GP, OSHINSKI JN, FRANCH RH, PETTIGREW RI, WALKER PG, YOGANATHAN AP. Quantification of the aortic regurgitant volume with magnetic resonance phase velocity mapping: a clinical investigation of the importance of imaging slice location. J Heart Valve Dis. 1998; 7: 94–101.

Investigations - Fitness for Management

Fact Explanation
Exercise ECG This will help to determine the functional capacity of the patient. This allows timely intervention for a better outcome. [1,2]
Full blood count Optimize hemoglobin before the surgery. Also full blood count helps to detect and treat infection.
Prothombin time and international normalized ratio Correct the coagulation profile before surgery.
Serum electrolytes Patient's renal functions should be assessed prior to the surgery.
References
  1. BORER JS, HOCHREITER C, HERROLD EM, SUPINO P, ASCHERMANN M, WENCKER D, DEVEREUX RB, ROMAN MJ, SZULC M, KLIGFIELD P, ISOM OW. Prediction of indications for valve replacement among asymptomatic or minimally symptomatic patients with chronic aortic regurgitation and normal left ventricular performance. Circulation. 1998; 97: 525–534.
  2. GREENBERG B, MASSIE B, THOMAS D, BRISTOW JD, CHEITLIN M, BROUDY D, SZLACHCIC J, KRISHNAMURTHY G. Association between the exercise ejection fraction response and systolic wall stress in patients with chronic aortic insufficiency. Circulation. 1985; 71: 458–465.

Investigations - Followup

Fact Explanation
2D Echocardiogram Asymptomatic patients with AR should be followed up annually with 2D echo if they develop symptoms. Evidence of left ventricular dilatation should be looked for. If an asymptomatic patient leads an active lifestyle with a normal echocardiogram findings, no other testing is necessary. [1] A post operative 2D echo will ensure the restoration of the normal valve function and left ventricular ejection fraction. [1]
References
  1. Guidelines for the Management of Patients With Valvular Heart Disease. Circulation.1998; 98: 1949-1984.

Investigations - Screening/Staging

Fact Explanation
2D echocardiogram 2D echo can grade the severity of valvular regurgitation and the degree of pulmonary hypertension. [1]
References
  1. Guidelines for the Management of Patients With Valvular Heart Disease. Circulation.1998; 98: 1949-1984.

Management - General Measures

Fact Explanation
Antibiotic prophylaxis against IE This is necessary especially if a prosthetic valve replacement has been performed. [1],[2] All patients with AR should be provided with antibiotic prophylaxis against IE. [3]
Treatment of syphilis. 4.8 to 6 million units of penicillin in a period of 8 to 10 days, should be administered. [4]
Treatment of Infective Endocarditis (IE) IE should be treated prior to any procedure.
Treat hypertension Systolic hypertension should be controlled with vasodilating drugs such as nifedipine or ACE inhibitors. [2,5]
References
  1. PARVEEN KUMAR, MICHAEL CLARK: Kumar and Clerk’s Clinical Medicine. 7th ed. London: Elsevier Limited, 2009
  2. Guidelines for the Management of Patients With Valvular Heart Disease. Circulation.1998; 98: 1949-1984. http://circ.ahajournals.org/content/98/18/1949.long
  3. RAFFI BEKEREDJIAN, PAUL A. GRAYBURN. Aortic Regurgitation. Circulation. 2005; 112: 125-134 http://circ.ahajournals.org/content/112/1/125.full#ref-30
  4. R. H. KAMPMEIER, HUGH J. MORGAN, The Specific Treatment of Syphilitic Aortitis. Circulation. 1952; 5: 771-778 http://circ.ahajournals.org/content/5/5/771
  5. MICHAEL KIM, MARY J. ROMAN, M. CHIARA CAVALLINI, JOSEPH E. SCHWARTZ THOMAS G. PICKERING, RICHARD B. DEVEREUX. Effect of Hypertension on Aortic Root Size and Prevalence of Aortic Regurgitation. Hypertension. 1996; 28: 47-52 https://hyper.ahajournals.org/content/28/1/47.full

Management - Specific Treatments

Fact Explanation
Aortic Valve Replacement (AVR) AVR should be considered if the AR is severe. [1] Symptomatic patients with mild to moderate left ventricular systolic dysfunction should undergo AVR. [1],[2] Once a prosthetic heart valve is being inserted the patient should be on life long warfarin and antibiotic prophylaxis against infective endocarditis when needed. [3]
Percutaneous transcatheter implantation of the aortic valve Better for patients who are not fit enough to undergo more invasive procedures. [2]
References
  1. Guidelines for the Management of Patients With Valvular Heart Disease. Circulation.1998; 98: 1949-1984. http://circ.ahajournals.org/content/98/18/1949.long
  2. BOUDJEMLINE Y, BONHOEFFER P. Steps toward percutaneous aortic valve replacement. Circulation. 2002; 105: 775–778.
  3. ASHLEY EA, NIEBAUER J: Cardiology Explained. London: Remedica; 2004. http://www.ncbi.nlm.nih.gov/books/NBK2208/