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Key Features

  • Rheumatic causes less common since advent of antibiotics

  • Nonrheumatic causes predominate

    • Congenitally bicuspid valve

    • Infective endocarditis

    • Hypertension

    • Marfan syndrome

    • Aortic dissection

    • Ankylosing spondylitis

  • Rarely atherosclerotic in nature

Clinical Findings

  • High-pitched, decrescendo aortic diastolic murmur along the left sternal border; no change with respiration

  • Hyperactive, enlarged left ventricle (LV)

  • Wide pulse pressure with peripheral signs

    • Water-hammer pulse or Corrigan pulse: rapid rise and fall with an elevated systolic and low diastolic pressure

    • Quincke pulses: pulsatile nail beds

    • Duroziez sign: to and fro murmur over a partially compressed femoral peripheral artery

    • Musset sign: head bob with each pulse

    • Hill sign: leg systolic pressure > 40 mm Hg higher than arm

  • Angina pectoris or atypical chest pain may occasionally be present

  • Associated coronary artery disease and syncope are less common than in aortic stenosis

  • Exertional dyspnea and fatigue are the most frequent symptoms, but paroxysmal nocturnal dyspnea and pulmonary edema may also occur

  • Usually slowly progressive and asymptomatic until middle age, although onset may sometimes be rapid, as in infective endocarditis or aortic dissection

Diagnosis

  • ECG: LV hypertrophy

  • Chest radiograph: Cardiomegaly with LV prominence and sometimes aortic dilation

  • Doppler echocardiography

    • Confirms the diagnosis

    • Estimates severity

  • Annual echocardiographic assessments of LV size and function are critical in determining the timing of valve replacement when the aortic regurgitation is severe

  • CT or MRI

    • Can estimate aortic root size

    • Can exclude ascending aneurysm

  • Cardiac catheterization

    • Can help quantify severity

    • Can evaluate the coronary and aortic root anatomy preoperatively

Treatment

  • Medications that decrease afterload can reduce regurgitation severity

    • Current recommendations advocate afterload reduction when there is associated systolic hypertension (systolic > 140 mm Hg)

  • Angiotensin receptor blockers (ARBs)

    • Preferred over β-blockers as additions to medical therapy in patients with Marfan disease

    • Reduce aortic stiffness (by blocking TGF-beta) and slow the rate of aortic dilation

  • Elective surgery is indicated

    • Once aortic regurgitation causes symptoms

    • Before symptoms emerge for those who have an ejection fraction < 50% or increasing end-systolic LV volume

    • For asymptomatic ascending aneurysm indicated when maximal dimension > 5.0 cm (> 4.5 cm in patients with Marfan syndrome)

  • Urgent surgery is indicated in acute aortic regurgitation (usually due to endocarditis or dissection)

  • Operative mortality is usually 3–5%

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