This document discusses atrial regurgitation, including its causes, pathophysiology, symptoms, signs, investigations, and treatment. It can be caused by diseases of the aortic valve like endocarditis or conditions affecting the aortic root like Marfan's syndrome. The pathophysiology involves blood refluxing from the aorta back into the left ventricle during diastole, enlarging the ventricle. Symptoms typically only develop late due to left ventricular failure and include angina and dyspnea. Physical exam may reveal a bounding pulse, displaced apex, and diastolic murmur. Investigations like echocardiogram can confirm the diagnosis. Treatment focuses on the underlying cause, and surgery is

1. Atrial Regurgitation
K. Kavindya M. Fernando
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2. Aortic regurgitation
• Can occur in disease affecting aortic
valve
– Endocarditis
– Diseases affecting the aortic root
• Marfan’s disease
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3. Pathophysiology
• Reflux of blood from aorta
• Through aortic valve
• Into left ventricle
• During diastole
• Enlarged ventricle
• Diastolic BP falls (due to aortic runoff
during diastole)
• Coronary perfusion decreased
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4. Aeitiology
 Any conditions resulting in incompetent
aortic leaflets
 Congenital
 Bicuspid valve
 Aortopathy
 Collagen disorders (e.g. Marfan’s)
 Ehler-Danlos
 Osteogenesis imperfecta
 Pseudoxanthoma elasticum

5. Aeitiology
 Acquired
 Rheumatic heart disease
 Dilated aorta (e.g. hypertension..)
 Degenerative
 Connective tissue disorders
 E.g. ankylosing spondylitis, rheumatoid arthritis,
Reiter’s syndrome, Giant-cell arteritis )
 Syphilis (chronic aortitis)
 Acute AI: aortic dissection, infective
endocarditis, trauma

6. Symptoms
• Symptoms occur late
• They do not develop until L ventricular
failure
• Angina pectoris is a frequent complaint
• Dyspnea
• Arrhythmias are relatively uncommon
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7. Signs
• Pulse : bounding collapsing pulse
• Apex:
– displaced laterally & downwards
– Forceful in quality
• Auscultation
– High pitched
– Early diastolic murmur
– Best heard at left sternal edge
– In 4th IC space
– Patient lying forward
– Breath held in expiration
• Volume overload : ejection systolic flow murmur
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8. Physical signs
 Widened pulse
pressure
 Systolic – diastolic =
pulse pressure
 High pitched, blowing,
decrescendo diastolic
murmur at LSB
 Best heard at end-
expiration & leaning
forward
 Hands & Knee position
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9. Physical signs
 Quincke’s sign:
 capillary pulsation

10. Physical signs
 Corrigan’s sign:
 water hammer pulse
 Bisferiens pulse
 (AS/AR > AR)

11. Physical signs
 De Musset’s sign:
 Head nodding with each heart beat
 Mueller’s sign:
 systolic pulsation of uvula

12. Physical signs
 Durosier’s sign:
 femoral retrograde bruits
 Traube’s sign:
 pistol shot femorals
 Hill’s sign:
 BP Lower extremity >BP Upper extremity by
 > 20 mm Hg - mild AR
 > 40 mm Hg – mod AR
 > 60 mm Hg – severe AR

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14. Investigations
• Chest X-ray
• Electrocardiogram
• Echocardiogram
• Cardiac catheterization
• Cardiac magnetic resonance
• Cardiac CT
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15. Investigations
• Chest X-ray
– Features of left ventricular failure
– Dilation of ascending aorta
– Ascending aorta may be calcified : syphilis
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16. Investigations
• ECG
– Features of left ventricular falilure
– Tall R waves
– Deeply inverted T waves in the left side
chest leads
– Deep S waves in the R side chest leasds
– Normally sinus rhythm is present
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17. Treatment
• Underlying cause may need treatment
– Syphilitic aortitis
– Infective endocarditis
• Acute aortic regurgitation
– Treatment with vasodilators & inotropes
• Patients with left ventricular dysfunctions
– ACE inhibitors
– Beta blockers (may slow aortic dilatation in
Marfan’s patients)
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18. Treatment
• Aortic surgery indicated
– In acute severe aortic regurgitation
(endocarditis)
– In symptomatic (dyspnea, angina) patients
with chronic severe aortic regurgitation
– Ehen symptomatic with L ventricular
ejection fraction is < 50%
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19. Treatment
• Mechanical prostheses & tissue valves
• Antibiotic prophylaxis against infective
endocarditis is not recommended
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