aortic regurgitation

1. AORTIC REGURGITATION
Dr Anuradha

2. Introduction
•Aortic regurgitation (AR), also known as Aortic
insufficiency (AI), is the leaking of the aortic
valve of the heart that causes blood to flow in
the reverse direction during ventricular diastole,
from the aorta into the left ventricle. As a
consequence, the cardiac muscle is forced to
work harder than normal.

3. Etiology
Valvular Root disease
• Congenital (BAV) • Root Dilation(80% idiopathic)
• Endocarditis (acute)
• Aortic dissection (acute)
• Rheumatic fever
• Cystic medial degeneration
( *with Mitral involvement )
• Marfan’s syndrome
• Myxomatous (prolapse)

4. • Traumatic Syphilis • Nonsyndromic familial aneurysm
• Ankylosing spondylitis
Aortitis
Trauma (acute)
Hypertension
Pathophysiology
Incompetent closure of the aortic valve

5. Diastolic reflux through the aortic valve can lead to left
ventricular volume overload (increased preload)
Increase in systolic stroke volume ( due to ventricular overload
) and low diastolic aortic pressure (due to aortic regurgitation)
Increased SYSTOLIC and Decreased DIASTOLIC Blood Pressure
WIDE PULSE PRESSURE
ACUTE AR CHRONIC AR

6. • The LV does not have sufficient • Gradual left ventricular volume
time to dilate in response to the overload that leads to a series of
sudden increase in volume. compensatory changes, including
• LV end-diastolic pressure LV enlargement and eccentric increases
rapidly(>40mmhg),
hypertrophy.
causing an increase in • Patients may remain pulmonary venous
pressure and asymptomatic during this period.
altering coronary flow dynamics. • The effective forward CO usually
• Patient develops dyspnea and is normal or only slightly reduced
pulmonary edema. In severe at rest, but often it fails to rise cases,
heart failure may develop. normally during exertion.

7. Clinical Features
•(3/4)Pts with Pure/Predominant Valvular AR-Men.
•Women-Primary Valvular AR who have associated
rheumatic mitral valve disease
In acute severe AR,LV diastolic pressure rises rapidly
with associated marked
elevations of LA and PA wedge pressures.

8. •Pulmonary edema and/or cardiogenic shock may
develop rapidly.
In Chronic severe AR-Long latent period, relatively
asymptomatic for as long as 10–15 years.
•Palpitation-early complaint.( esp. on lying )
•Exertional dyspnea-symptom of diminished cardiac
reserve.

9. •Orthopnea, paroxysmal nocturnal dyspnea, and
excessive diaphoresis, Anginal chest pain with severe
AR.
On Physical Examination
ACUTE AR
•Signs of CHF or shock
•Tachycardia
•Peripheral
vasoconstriction
•Cyanosis
•Pulmonary edema

10. •*Arterial pulsus alternans
CHRONIC AR
•Manifestations are due
to widened pulse
pressure.
•Diastolic pressures are
often lower than 60 mm
Hg, with pulse pressures
often exceeding 100 mm
Hg
Signs in Chronic AR

11. •Becker sign - Visible systolic pulsations of the retinal
arterioles
•Corrigan’s sign - Dancing Carotids
•Corrigan pulse ("water-hammer" pulse) - Abrupt
distention and quick collapse on palpation of the
peripheral arterial pulse
•de Musset sign - Bobbing motion of the patient's head
with each heartbeat

12. •*Hill sign - Popliteal cuff systolic blood pressure 40
mm Hg higher than brachial cuff systolic blood
pressure(>60-severe)
•Duroziez sign - Systolic murmur over the femoral
artery with proximal compression of the artery, and
diastolic murmur with distal compression.
•Quincke sign - Visible pulsations of the fingernail bed
with light compression of the fingernail

13. •Traube sign ("pistol-shot" pulse) - Booming systolic
and diastolic sounds auscultated over the femoral
artery
•Rosenbach’s sign—Pulsations of liver
•Gerhardt’s sign—pulsations over enlarged spleen
PALPATION
•LV impulse is Hyperdynamic & displaced

14. *laterally and inferiorly
•A diastolic thrill may be palpable along
the left sternal border.
AUSCULTATION
•Soft S1 (only in acute AR due to premature
closure of MV)

15. •A high frequency early decrescendo diastolic
murmur in aortic area.
•Duration of murmur >2/3 of diastole
indicates severity.
•*Austin Flint murmur
Investigations
ECG

16. • In patients with chronic severe AR, the ECG signs of LV hypertrophy
become manifest.
2 D Echocardiogram with Doppler
• LV size is increased in chronic AR. A rapid, high-frequency diastolic
fluttering of the anterior mitral leaflet produced by the impact of
the regurgitant jet is a characteristic finding.
Chest X-ray
• The apex is displaced downward and to the left in the frontal
projection.
Cardiac Catheterization and Angiography

17. • Dilated LV, Aortic Regurgitation, Dilated Aortic Root
Treatment

18. ACUTE AR
•Diuretics
•IV Nitroprusside
•SURGERY(recommended)
*Beta-Blockers and Intraaortic
balloon counter pulsations are
Contraindicated
CHRONIC AR
•Vasodilators- Hydralazine,
DHPs, CCB
•Penicillin prophylaxis in
syphilitic
•Beta-Blocker in Aortic root
Dilation
•SURGERY-Valve
replacement/repair

19. Take Home Message.
•Blood leaks across aortic valve
•Primary Valve Disease OR Primary Aortic Root Disease
•Increased preload, stroke volume
•High Pitched Blowing Early Decrescendo diastolic
murmur in 2nd Aortic area.(root dilation better heard in
1st Aortic Area).

20. •Wide pulse pressure symptoms(>60)- Corrigan pulse and
Sign
•Treatment (severe disease): Surgery
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