The daily educational pearl – Aortic regurgitation

Aortic regurgitation

Causes:

chronic

– rheumatic heart disease

– congenital – bicuspid aortic valve, VSD

– seronegative arthropathies, ankylosing spondylitis in particular

– aortic root dilatation in Marfan’s syndrome, aortitis (rheumatoid, syphilis)

– idiopathic

– secondary to some medications (e.g. fenfluramine)

acute

– infective endocarditis

– dissecting aneurysm aortic root

– trauma

Acute aortic regurgitation is a medical emergency – the patients usually present in florid pulmonary oedema and the mortality rate is very high unless they have urgent aortic valve replacement.

 

Symptoms:

dyspnoea

fatigue

palpitations

exertional angina

 

Signs: (yes, all those ones…)

collapsing pulse, “water hammer”pulse (Watson’s)

wide pulse pressure

displaced / hyperkinetic apex beat

diastolic thrill at the left sternal edge

descrescendo, high-pitched diastolic murmur, loudest in 3rd & 4th left intercostal spaces (an associated ejection systolic murmur is often present, due to either associated aortic stenosis or to high flow across a normal-diameter aortic valve)

low-pitched, rumbling mid-diastolic & presystolic murmur, audible at apex (Austin Flint murmur)

 

In chronic AR:

Corrigan’s sign (rapid upstroke and collapse of the carotid pulse)

de Musset’s sign (head nodding in time with the heart beat)

Quincke’s sign (pulsation of the capillaries in the nailbed)

Duroziez’s (systolic and diastolic murmurs heard over the femoral artery when it is gradually compressed with the stethoscope)

Traube’s sign (double sound heard over the femoral artery on it is compressed distally)

Muller’s sign (pulsations of uvula)

Becker’s sign (pulsations of retinal vessels)

Lighthouse sign (blanching & flushing of forehead)

Landolfi’s sign (alternating constriction & dilatation of pupil)

 

ECG findings:

left ventricular hypertrophy

 

Severe aortic regurgitation:

collapsing pulse

wide pulse pressure

long descrescendo diastolic murmur

presence of S3

presence of an Austin Flint murmur

signs of left ventricular failure

echo – regurgitant fraction > 60% stroke volume

 

Management precautions:

– AVOID bradycardia (target HR 80 – 100/min), AVOID hypovolaemia, AVOID myocardial depression

– if inotropic / vasopressor support is needed, use inotropes (dopamine / dobutamine) early

– in case of acute pulmonary oedema in a patient with aortic regurgitation consider using both GTN infusion and dopamine / dobutamine to increase forward flow and decrease left ventricular end-diastolic pressure

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