• Clinical science

Aortic regurgitation (Aortic insufficiency)

Abstract

Aortic regurgitation (AR) is a valvular heart disease characterized by incomplete closure of the aortic valve that leads to reflux of blood from the aorta into the left ventricle (LV) during diastole. Aortic regurgitation may be acute (occurring primarily after bacterial endocarditis or aortic dissection) or chronic (due to congenital bicuspid valve or rheumatic fever). In most cases, acute AR leads to rapid deterioration of LV function with subsequent pulmonary edema and cardiac decompensation. Frequently, chronic AR may remain compensated for a long period of time, becoming symptomatic only when left heart failure develops. Auscultation reveals an S3 and a high-pitched, decrescendo early diastolic murmur. Another characteristic diagnostic finding is widened pulse pressure. Echocardiography is the most important diagnostic tool, both for confirming the diagnosis and determining the severity of disease. In asymptomatic patients, conservative treatment consists of symptom management and physical activity as tolerated. However, symptomatic patients or those with severely reduced LV function should undergo surgical aortic valve replacement.

Etiology

See also heart valve disease

References:[1][2]

Pathophysiology

References:[1][2]

Clinical features

References:[1]

Diagnostics

Physical examination

  • For detailed information about the individual tests, see cardiovascular examination.
  • High pulse pressure
    • Water hammer pulse of peripheral arteries characterized by rapid upstroke and downstroke
    • Pulsing of carotid arteries with rapid upstroke and downstroke
    • Visible capillary pulse (Quincke sign)
    • Nodding of the head with each pulse
  • Point of maximal impulse (PMI): displaced inferolaterally, diffuse, and hyperdynamic
  • Auscultation
    • S3
    • High-pitched, blowing, decrescendo early diastolic murmur
      • AR due to valvular disease: best heard in the left third and fourth intercostal spaces and along the left sternal border (Erb point)
      • AR due to aortic root disease (e.g., aortic dissection): best heard along the right sternal border
      • Worsens with squatting and handgrip
    • Austin Flint murmur
    • In more severe stages, possibly a harsh, crescendo-decrescendo mid-systolic murmur that resembles the ejection murmur heard in aortic stenosis

Confirmatory tests

  • Transthoracic echocardiogram (TTE)
    • Indicated for suspected AR as well as to monitor confirmed AR to determine optimal timing of surgery
    • Findings
      • Abnormal valve leaflets
      • Regurgitant AR jet on Doppler
      • Increased LV size and volume
      • LV ejection fraction < 55%
  • Transesophageal echocardiogram (TEE): indicated if suboptimal or nondiagnostic TTE

Screening tests (optional)

  • ECG
    • Signs of left ventricular hypertrophy
  • Chest x-ray
    • Prominent aortic root/arch
    • Enlarged cardiac silhouette

References:[3][4][1][2]

Treatment

Conservative

  • Indication: asymptomatic patients and symptomatic patients who are not candidates for surgical treatment
  • Treatment of heart failure
  • Physical activity , but without excessive straining

Surgical

  • Indication: patients with acute severe AR and chronic AR with symptoms or with significantly reduced pump function
  • Surgical procedure: aortic valve replacement (occasionally valve reconstruction is possible) and long-term anticoagulation therapy for mechanical valve

References:[1][2]

Prognosis

  • Asymptomatic patients with normal EF: progression to symptoms or LV dysfunction at a rate of < 6% per year
  • Asymptomatic patients with decreased EF: progression to symptoms at a rate of > 25% per year
  • Symptomatic patients: mortality rate is > 10% per year

References:[1]

last updated 12/16/2018
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