Aortic Regurgitation

Relevant physical signs

• Stigmata of infective endocarditis
• Collapsing pulse
• Eponymous clinical signs associated with aortic regurgitation:
  • Quicke’s sign: visible capillary pulsations in the fingernails
  • De Musset’s sign: nodding of the head with each heartbeat
  • Becker’s sign: visible pulsations of retinal arteries and pupils
  • Muller’s sign: systolic pulsations of the uvula
  • Corrigan’s pulse: visible carotid pulsations
  • Rosenbach’s sign: systolic pulsations of the liver
  • Gerhard’s sign: systolic pulsations of the spleen
  • Traube’s sign: pistol shot femorals
  • Duroziez’s sign: ejection systolic and diastolic murmurs heard with the stethoscope when the bell is used to compress the femoral arteries
  • Hill’s sign: popliteal > brachial systolic pressure by > 60mmHg
  • Mayne’s sign: drop in diastolic blood pressure by > 15mmHg with arm elevation
• JVP may be elevated with pulmonary hypertension
• Displaced apex beat with thrusting quality (hyperdynamic circulation and volume-overloaded LV)
• Parasternal heave in pulmonary hypertension
• Check for thrill over LLSE or aortic area
• Auscultation:
  • S1 usually normal
  • S2 – aortic component usually soft (not a marker of severity), pulmonary component loud if PH
  • S3 – rapid ventricular filling from increased pre-load; marker of severe AR
  • Early diastolic murmur heard best over the LLSE with the patient leaned forward and in expiration
    • Length of murmur correlates with severity
    • High-pitched, decrescendo murmur
  • Ejection flow murmur over the aortic area (does not equate to co-existent aortic stenosis) from increased flow across the aortic valve
  • Austin-Flint murmur
    • Functional mitral stenosis caused by regurgitant jet striking mitral valve leaflets
    • Marker of severe AR
    • Distinguished from MS in that there is no opening snap, S1 is not loud
• Signs of congestive cardiac failure
• Signs of an underlying cause:
  • Bicuspid aortic valve: ejection click in early systole
  • Marfan’s syndrome: high, arched palate, tall stature, long arms
  • Syphilitic aortitis: Argyll-Robertson pupil (reacts to accommodation but not to light)
  • Systemic lupus erythematosus: rash, oral ulcers, alopecia
  • Rheumatoid arthritis: symmetrical deforming polyarthropathy of the hands
  • Ankylosing spondylitis: kyphosis, restricted forward flexion of spine
  • Osteogenesis imperfecta: blue sclerae, hearing aids
  • Pseudoxanthoma elasticum: loose skin over neck and axillae
• Complete examination:
  • Blood pressure – wide pulse pressure / severe hypertension
  • Temperature – infective endocarditis

Differential diagnosis

• Pulmonary regurgitation
• Stenosis of the left anterior descending artery

Clinical markers of severe aortic regurgitation

• Wide pulse pressure
• Long diastolic murmur (may be very short if extremely severe – rapid equalization of aortic and ventricular pressures)
• Austin-Flint murmur
• Presence of S3
• Displaced apex beat
• Signs of pulmonary hypertension
• Signs of congestive cardiac failure

Causes of aortic regurgitation

• Chronic
  • Bicuspid aortic valve
  • Hypertension
  • Rheumatic fever
  • Aortitis
    • Syphilis
    • Takayasu’s disease
    • Ankylosing spondylitis
    • Reiter’s syndrome
    • Psoriatic arthropathy
  • Rheumatoid arthritis
  • Systemic lupus erythematosus
  • Connective tissue disorders
    • Marfan’s syndrome
    • Ehlers-Danlos syndrome
    • Osteogenesis imperfecta
    • Pseudoxanthoma elasticum
  • Peri-membranous ventricular septal defect with prolapse of the right coronary cusp
• Acute
  • Infective endocarditis
  • Aortic dissection
  • Ruptured sinus of Valsalva aneurysm

Causes of a collapsing pulse

• Aortic regurgitation
• Severe anaemia
• Severe mitral regurgitation
• Pregnancy
• High fever
• Thyrotoxicosis
• Patent ductus arteriosus
• Arterio-venous fistula

Investigations

• Electrocardiogram: evidence of LVH or strain
• Chest radiography: pulmonary oedema, cardiomegaly, widened aorta
• Transthoracic echocardiogram
  • Confirm diagnosis
  • Assess severity of aortic regurgitation
  • Look for complications such as infective endocarditis
  • Look for an underlying cause
• Coronary angiogram to look for co-existent coronary artery disease

Management

• Multidisciplinary
  • Patient education – 4% per year will develop congestive cardiac failure
  • Cardiac rehabilitation if in CCF
• Medical management
  • Vasodilators for hypertension
  • Diuretics, angiotensin-converting enzyme inhibitors, beta blockers if in cardiac failure
  • Treat infective endocarditis
• Surgical valve replacement
  • Severe aortic regurgitation with symptoms of heart failure
  • Severe aortic regurgitation with angina
  • Ejection fraction < 50%
  • End-systolic diameter > 55mm
  • Aortic root diameter ≥ 50mm

Summary

Sir, this patient has aortic regurgitation. The pulse was regular and collapsing in character. The apex beat is displaced inferolaterally, and has a thrusting character. On auscultation of the precordium, there is a high-pitched, 3/6 decrescendo murmur heard loudest over the lower left sternal edge in expiration. This is associated with an ejection systolic murmur over the aortic area – differentials for this would be co-existent aortic stenosis, or a flow murmur from a volume overloaded left ventricle. There was no associated Austin-Flint murmur and no third heart sound was heard. Clinically, the patient is in congestive cardiac failure, with crepitations heard over the lung bases, an elevated jugular venous pulsation and peripheral oedema. There are no peripheral stigmata of infective endocarditis.

The patient is not Marfanoid, and there is no symmetrical deforming polyarthropathy to suggest underlying rheumatoid arthritis or kyphosis to suggest ankylosing spondylitis. There is no rash to suggest psoriasis. The possible causes of his aortic regurgitation are therefore rheumatic heart disease, infective endocarditis or a bicuspid aortic valve.

In summary, this patient has aortic regurgitation which is at least moderately severe.