Aortic Regurgitation

KEY FEATURES

Essentials of Diagnosis

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

• Wide pulse pressure and high stroke volume leads to many of the peripheral examination findings

• Hyperactive, enlarged left ventricle (LV)

• Diastolic murmur along left sternal border

• Electrocardiogram (ECG) shows LV hypertrophy; radiograph shows LV dilation

• Echocardiography/Doppler is diagnostic

• Surgery for symptoms, ejection fraction < 50%, 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 develop rapidly)

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

  • Pulse pressure may not be widened