Phonocardiograms from normal and abnormal heart sounds
The physical examination of an individual with aortic insufficiency involves
auscultation of the heart to listen for the murmur of aortic insufficiency and the
S3 heart sound (S3 gallop correlates with development of LV dysfunction).
murmur of chronic aortic insufficiency is typically described as early diastolic and
decrescendo, which is best heard in the third left intercostal space and may
radiate along the left sternal border.
If there is increased stroke volume of the left ventricle due to volume overload, an
ejection systolic 'flow' murmur may also be present when auscultating the same
aortic area. Unless there is concomitant aortic valve stenosis, the murmur should
not start with an ejection click.
There may also be an Austin Flint murmur,
a soft mid-diastolic rumble heard at
the apical area. It appears when regurgitant jet from the severe aortic
insufficiency renders partial closure of the anterior mitral leaflet.
Peripheral physical signs of aortic insufficiency are related to the high pulse
pressure and the rapid decrease in blood pressure during diastole due to blood
returning to the heart (the wrong way) from the aorta through the incompetent
aortic valve, although the usefulness of some of the eponymous signs has been
large-volume, 'collapsing' pulse also known as:
o Watson's water hammer pulse
o Corrigan's pulse (rapid upstroke and collapse of the carotid artery
low diastolic and increased pulse pressure
de Musset's sign (head nodding in time with the heart beat)
Quincke's sign (pulsation of the capillary bed in the nail; named for Heinrich
Traube's sign (a 'pistol shot' systolic sound heard over the femoral artery;
named for Ludwig Traube)
Duroziez's sign (systolic and diastolic murmurs heard over the femoral
artery when it is gradually compressed with the stethoscope)
Also, these are usually less detectable in acute cases.
Less used signs include:
Lighthouse sign (blanching & flushing of forehead)
Landolfi's sign (alternating constriction & dilatation of pupil)
Becker's sign (pulsations of retinal vessels)
Müller's sign (pulsations of uvula)
Mayen's sign (diastolic drop of BP>15 mm Hg with arm raised)
Rosenbach's sign (pulsatile liver)
Gerhardt's sign (enlarged spleen)
Hill's sign - a ≥ 20 mmHg difference in popliteal and brachial systolic cuff
pressures, seen in chronic severe AI. Considered to be an artefact of
sphygmomanometric lower limb pressure measurement.
Lincoln sign (pulsatile popliteal)
Sherman sign (dorsalis pedis pulse is quickly located & unexpectedly
prominent in age>75 yr)
Ashrafian sign (Pulsatile pseudo-proptosis)
Unfortunately, none of the above putative signs of aortic insufficiency is of utility
in making the diagnosis,
but they may help as pointers. What is of value is
hearing a diastolic murmur itself, whether or not the above signs are present.
Indications for surgery for chronic severe aortic insufficiency
Absent > 50%
Abnormal exercise test, severe LV dilatation
(systolic ventricular diameter >55 mm
Absent <=50 %
Cardiac surgery for other cause (i.e.: CAD, other valvular disease, ascending aortic
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Aortic insufficiency is a heart valve disease in which the aortic valve does not
close tightly. This leads to the backward flow of blood from the aorta (the largest
blood vessel) into the left ventricle (a chamber of the heart).
Aortic insufficiency can result from any condition that keeps the aortic valve from
closing all the way. A small amount of blood comes back each time the heart
The condition causes widening (dilation) of the left lower chamber of the heart.
Larger amounts of blood leave the heart with each squeeze or contraction. This
leads to a strong and forceful pulse (bounding pulse). Over time, the heart
becomes less able to pump blood to the body.
In the past, rheumatic fever was the main cause of aortic insufficiency. Now that
antibiotics are used to treat rheumatic fever, other causes are more commonly
Causes of aortic insufficiency may include:
Congenital (present at birth) valve problems, such as bicuspid valve
High blood pressure
Systemic lupus erythematosus
Aortic insufficiency is most common in men between the ages of 30 and 60.
Aortic insufficiency often has no symptoms for many years. Symptoms may occur
slowly or suddenly.
Chest pain, angina type (rare)
o Under the chest bone; pain may move to other areas of the body,
most often the left side of the chest
o Crushing, squeezing, pressure, tightness
o Pain increases with exercise and goes away with rest
Palpitations (sensation of the heart beating)
Shortness of breath with activity or when lying down
Swelling of the feet, legs, or abdomen
Uneven, rapid, racing, pounding, or fluttering pulse
Weakness, more often with activity
Exams and Tests
Signs may include:
A heart murmur when the health care provider listens to the chest with a
A very forceful beating of the heart
The head may bob in time with the heartbeat
Hard pulses in the arms and legs
Low diastolic blood pressure
Signs of fluid in the lungs
Aortic insufficiency may be seen on:
ultrasound examination of the heart
Left heart catheterization
MRI of the heart
Transesophageal echocardiogram (TEE)
A chest x-ray may show swelling of the left lower heart chamber.
Lab tests cannot diagnose aortic insufficiency, but they may be used to rule out
other disorders or causes.
If there are no symptoms or if symptoms are mild, you may only need to get an
echocardiogram from time to time and be monitored by a health care provider.
If your blood pressure is high, then treatment with certain blood pressure
medications may help slow the worsening of aortic regurgitation.
ACE inhibitor drugs and diuretics (water pills) may be prescribed for more
moderate or severe symptoms.
In the past, most patients with heart valve problems were given antibiotics before
dental work or an invasive procedure, such as colonoscopy. The antibiotics were
given to prevent an infection of the damaged heart. However, antibiotics are now
used much less often before dental work and other procedures.
You may need to limit activity that requires more work from your heart. Talk to
your health care provider.
Surgery to repair or replace the aortic valve corrects aortic insufficiency. The
decision to have aortic valve replacement depends on your symptoms and the
condition and function of your heart.
You may also need surgery to repair the aorta if it is widened.
Aortic insufficiency is curable with surgical repair. This can completely relieve
symptoms, unless severe heart failure is present or other complications develop.
Without treatment, patients with angina or congestive heart failure due to aortic
insufficiency do poorly.
Abnormal heart rhythms
Infection in the heart
When to Contact a Medical Professional
Call your health care provider if:
You have symptoms of aortic insufficiency
You have aortic insufficiency and symptoms worsen or new symptoms
develop, especially chest pain, difficulty breathing, or edema (swelling)
Blood pressure control is very important if you are at risk for aortic regurgitation.
Aortic valve prolapse; Aortic regurgitation