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Title: Aortic Regurgitation - Clinical Summary
Description: This provides a summary of AR as a condition including the background, symptoms and signs/clinical presentation, investigations to diagnose the condition and management plan.
Description: This provides a summary of AR as a condition including the background, symptoms and signs/clinical presentation, investigations to diagnose the condition and management plan.
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AORTIC REGURGITATION
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Presentation
Acute AR ® features of heart failure
§ Sudden dyspnoea
§ Chest pain
§ Bibasal crackles
§ Raised JVP
Chronic AR ® may be asymptomatic for decades
§ Palpitations
§ Angina
§ Dyspnoea
§ Collapsing water hammer pulse, wide pulse pressure
§ Bounding carotid pulse
§ Chest signs ® displaced apex, ejection diastolic murmur, soft S1 and S2, absent 2nd heart sound
AR Murmur ® decrescendo diastolic murmur, systolic ejection murmur
...
Eponymous signs
§ De Musset’s ® head nodding with heart beat
§ Quincke’s ® pulsation of nail beds
§ Traube’s ® pistol shot femorals
§ Duroziez’s ® to and fro murmur heard when stethoscope compresses femoral vessels
§ Muller’s ® pulsation of uvula
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Pathophysiology
Aortic regurgitation (AR) results from an incompetent aortic valve, causing regurgitant flow of blood in diastole
...
§ Aortic root
o Connective tissue disorder ® Marfan’s syndrome, EDS
o Aortitis ® inflammation of aortic root
§ May be associated with chronic inflammatory conditions e
...
RA, ankylosing spondylitis
§ May occur in Takayasu arteritis also
o Aortic dissection ® in Stanford A dissections, secondary to impaired leaflet coaptation or prolapse
§ Causes acute disease regurgitation
§ Medical emergency
§ Aortic regurgitation may develop acutely or chronically
o Acute ® medical emergency
§ Ac acute rise in left atrial pressure ® pulmonary oedema and cardiogenic shock
§ Valvular incompetence occurs rapidly, no time for compensatory changes to develop
§ Regurgitation of blood during diastole ® increase in left ventricular EDV and pressure
§ This causes the following effects:
• Reduced coronary flow ® coronaries fill mostly during diastole, regurgitant flow at this time
reduces filling, causing angina or myocardial ischaemia
• Increased end-diastolic pressure ® causes increased pulmonary pressures with resulting
pulmonary oedema and dyspnoea and severly, cardiogenic shock
o
Chronic ® may remain asymptomatic for decades
§ Valvular incompetence develops slowly
§ Regurgitation of blood during diastole ® increase in left ventricular end-diastolic volume (preload)
§ This leads to systolic and diastolic dysfunction
§ Left ventricular dilatation develops with eccentric hypertrophy
§ Dilatation allows for an increase stroke volume compensating for regurgitant flow, supported by the
ventricular hypertrophy
§ The changes maintain ejection fraction with a greater preload leading to greater contractility
§ Eventually, further increases in preload can’t be met by greater contractility ® heart failure
...
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Investigation
The main investigation is an echocardiogram
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Bloods
§ FBC, U&E, cholesterol, clotting
...
g
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Imaging
§ CXR ® cardiomegaly, dilated ascending aorta (aortic root pathology)
§ CT/MRI ® estimate regurgitant fraction, used especially in patients with aortic dilatation
§ Angiography ® in patients with chronic AR undergoing surgery to assess for concomitant coronary artery disease may
requiring bypass
...
This is indicated in severe disease, symptomatic disease or in
presence of enlarged ascending aorta
...
Chronic AR
§ Surgical management indicated in patients with:
o Significant enlargement of ascending aorta
o Symptomatically severe
o Severe AR with LVEF <50% or LVEDD >70 mm or LVESD >50 mm
o Marfan’s with aortic root disease with maximal ascending aorta diameter >50 mm
§ Decision of mechanical vs bioprosthetic valve should take into account patient factors and wishes
o Mechanical ® require long-term anticoagulation, long lifespan, suited to younger patients
o Bioprosthetic ® no need for long-term anticoagulation, limited life span (10 years), suited to older patients
§ TAVI used in patients who surgery is contraindicated in
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Useful Links:
https://www
...
com/watch?v=_k5u933BIbo
Title: Aortic Regurgitation - Clinical Summary
Description: This provides a summary of AR as a condition including the background, symptoms and signs/clinical presentation, investigations to diagnose the condition and management plan.
Description: This provides a summary of AR as a condition including the background, symptoms and signs/clinical presentation, investigations to diagnose the condition and management plan.