Aortic Regurgitation

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

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

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

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 beta-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%