Aortic regurgitation (AR)

Causes of aortic regurgitation:

Acute AR:

• Acute rheumatic fever
• IE
• Aortic dissection

Chronic AR:

• Rheumatic heart disease
• Syphilis
• RA
• Ankylosing spondylitis
• Severe HT
• Marfan’s syndrome
• Osteogenesis imperfecta

Symptoms:

• Significant symptoms do not develop until LV failure occurs
• A common symptom is ‘pounding of the heart’ because of the increased LV size and its vigorous pulsation
• Dyspnoea

Signs:

Pulse: Sinus rhythm, large volume, collapsing

Blood pressure: Wide pulse pressure

Apex: Displaced, diffuse, heaving

Murmur: (1) High pitched early diastolic at LSE

(2) Ejection systolic at base and into neck

(3) Mid-diastolic rumble at apex (Austin-Flint)

De Musset’s sign Head nodding with each heart beat

Quincke’s sign Visible capillary pulsation in the nail beds

Pistol shot femorals A sharp bang heard on auscultation over the femoral arteries in time with each heart beat

Investigations:

CXR:

• LV enlargement
• Ascending aortic wall ,ay be calcified in syphilis

ECG:

• Left ventricular hypertrophy
• Usually sinus rhythm

Echocardiogram

Treatment:

• Treat the underlying cause (e.g. IE, syphilis) if possible

• Treatment usually requires aortic valve replacement but the timing of surgery is important:
• Because symptoms do not develop until the myocardium fails and because the myocardium does not recover fully after surgery, it is important to operate before significant symptoms occur
• The timing of the operation is best determined according to haemodynamic, echocardiographic or nuclear angiographic criteria

• Antibiotic prophylaxis against IE is necessary, even if a prosthetic valve replacement has been performed