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Aortic Regurgitation

For further information, see CMDT Part 10-19: Aortic Regurgitation

KEY FEATURES

Essentials of Diagnosis

  • Usually asymptomatic until middle age; presents with left-sided failure or rarely chest pain

  • Echocardiography/Doppler is diagnostic

  • Surgery for symptoms, ejection fraction < 50%, left ventricular (LV) end-systolic dimension > 50 mm, or LV end-diastolic dimension > 65 mm

General Considerations

  • Rheumatic causes less common than nonrheumatic causes 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

Symptoms and Signs

  • Clinical presentation is determined by the rapidity with which regurgitation develops

    • Usually slowly progressive and asymptomatic until middle age

    • Onset may sometimes be rapid, as in infective endocarditis or aortic dissection

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

  • Angina pectoris or atypical chest pain may occasionally be present

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

  • Chronic aortic regurgitation (see Table 10–2)

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

    • Hyperactive, enlarged 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

  • Acute aortic regurgitation

    • Pulmonary edema from LV failure (may occur rapidly)

    • Diastolic murmur may be shorter and less intense than in chronic aortic regurgitation

    • Pulse pressure may not be widened

Table 10–2.Differential diagnosis of valvular heart disease.
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Table 10–2. Differential diagnosis of valvular heart disease.
  Mitral Stenosis Mitral Regurgitation Aortic Stenosis Aortic Regurgitation Tricuspid Stenosis Tricuspid Regurgitation
Inspection Malar flush, precordial bulge, and diffuse pulsation in young patients. Usually prominent and hyperdynamic apical impulse to left of MCL. Sustained PMI, prominent atrial filling wave. Hyperdynamic PMI to left of MCL and downward. Visible carotid pulsations. Pulsating nailbeds (Quincke sign), head bob (deMusset sign). Giant a wave in jugular pulse with sinus rhythm. Peripheral edema or ascites, or both. Large v wave in jugular pulse; time with carotid pulsation. Peripheral edema or ascites, or both.
Palpation “Tapping” sensation over area of expected PMI. RV pulsation in left third to fifth ICS parasternally when pulmonary hypertension is present. P2 may be palpable. Forceful, brisk PMI; systolic thrill over PMI. Pulse normal, small, or slightly collapsing. Powerful, heaving PMI to left and slightly below MCL. Systolic thrill over aortic area, sternal notch, or carotid arteries in severe disease. Small and slowly rising carotid pulse. If bicuspid AS, check ...

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