Aortic Regurgitation ✅

Related Subjects: |Aortic Anatomy |Acute Coronary Syndrome (ACS) General |Aortic Dissection |Acute Heart Failure and Pulmonary Oedema |Aortic Regurgitation (Incompetence) |Aortic Stenosis |Aortic Sclerosis |Transcatheter aortic valve implantation (TAVI)

🫀 Aortic Regurgitation (AR / Aortic Incompetence) = backward flow from the aorta into the LV during diastole → LV volume overload, eccentric hypertrophy, progressive dilatation. ⚡ Chronic AR: insidious, tolerated for years. Acute AR: catastrophic, flash pulmonary oedema, cardiogenic shock 🚨.

📖 Overview

• Prevalence: lower than AS, but significant in younger adults & connective tissue disorders.
• Pathophysiology: Volume overload → eccentric LV hypertrophy → dilatation → eventual LV dysfunction + HF.
• Severe AR can reduce coronary perfusion → exertional angina despite normal coronaries 💔.

🫀 Anatomy & Valve Function

• Normal valve: 3 cusps (L, R, N). Effective coaptation prevents regurgitation.
• Sinuses of Valsalva fill coronaries during diastole.

🧬 Causes & Aetiology

🩺 Clinical Features

• Acute AR: Severe dyspnoea, hypotension, flash pulmonary oedema, shock 🚨.
• Chronic AR: Exertional dyspnoea, orthopnoea, palpitations, angina, HF over years.
• Murmur: High-pitched early diastolic “blowing” murmur, LSE, louder on sitting forward 🌬️.
• Pulse: Wide pulse pressure; collapsing “water-hammer” / Corrigan’s pulse 💓.

👨‍🏫 Classical Signs

• Austin Flint: mid-diastolic rumble (jet hits mitral leaflet)
• Corrigan: bounding carotid pulse 💥
• Quincke: capillary pulsations in nailbed
• De Musset: head bobbing with each beat
• Traube: “pistol shot” femoral sounds 🔫
• Hill’s Sign: popliteal SBP > brachial by ≥20 mmHg
• Landolfi: pupillary pulsation synchronized with heartbeat 👁️
• Muller: uvula pulsation
• Lighthouse: facial capillary pulsations 🌞
• Rosenbach: liver pulsation
• Gerhardt: spleen pulsation
• Mayne: ≥15 mmHg diastolic drop on arm elevation
• Becker: retinal artery pulsations 👀

🧪 Investigations

• Bloods: FBC, CRP, cultures if infective endocarditis suspected 🦠.
• CXR: Cardiomegaly, LV enlargement, aortic root dilatation.
• ECG: LVH ± conduction delay, ischaemic changes.
• Echocardiography: Gold standard. Assess valve, LV size, EF, regurgitant volume via colour Doppler.
• Cardiac MRI: Precise regurgitant volume, aortic root dimension measurement 🖥️.
• Cardiac Catheterisation: Coronary anatomy, AR severity, pre-surgery planning.
• Blood tests: Treponemal serology, inflammatory markers in aortic disease.

⚡ Complications

• LV failure → pulmonary oedema 🫁
• Acute decompensation: endocarditis, dissection
• Aortic root aneurysm or rupture 💥
• Sudden death: arrhythmia, shock ⚡

💊 Management

🫀 Aortic Regurgitation (AR, “Aortic Incompetence”) = backward flow of blood from the aorta into the LV during diastole. ➡️ Causes LV volume overload, eccentric hypertrophy, and progressive dilatation. ⚡ Chronic AR develops slowly; Acute AR can be catastrophic (flash pulmonary oedema + shock).

🩺 Management of Aortic Regurgitation

1️⃣ Initial Assessment

• ✅ Assess hemodynamic stability: BP, HR, O₂ saturation, signs of pulmonary oedema 🫁
• ✅ Evaluate symptoms: dyspnoea, angina 💔, palpitations, syncope 💫
• ✅ Determine acute vs chronic AR:
  • Acute: rapid onset, pulmonary oedema, cardiogenic shock 🚨
  • Chronic: may be asymptomatic for years, progressive LV dilatation
• ✅ Identify underlying cause: endocarditis, bicuspid valve, aortic root disease, trauma, hypertension

2️⃣ Medical Management (Chronic / Bridging)

• 💊 Vasodilators: Reduce afterload, improve forward flow
  • ACE inhibitors (ramipril, enalapril)
  • Nifedipine, hydralazine if ACEi contraindicated
• 💧 Diuretics: For symptom relief; careful to maintain adequate preload
• 💓 Rate control for AF: Digoxin, amiodarone
• 🩺 Blood pressure control: Maintain systolic BP <120–130 mmHg if tolerated
• ❌ Avoid β-blockers in acute AR (slows HR → worsens regurgitation), except chronic AR in CTD/Marfan
• 📊 Surveillance: Serial echocardiography every 6–12 months; monitor LVEDD, LVESD, EF

3️⃣ Acute Severe AR (Emergency)

• 🚨 Urgent cardiothoracic referral
• 💉 Stabilization:
  • IV diuretics for pulmonary oedema
  • Oxygen, hemodynamic monitoring
  • Vasodilators cautiously if hypertensive
• ❌ Avoid aggressive β-blockade or preload-reducing agents
• 🔪 Emergency surgery: Urgent SAVR (surgical valve replacement)

4️⃣ Surgical / Interventional Management

• 🔪 SAVR (Surgical Aortic Valve Replacement) – gold standard
  • Indications: symptomatic severe AR, or asymptomatic with LVEF <50%, LVESD ≥50 mm, LVEDD ≥70 mm
• 🩻 TAVI / TAVR: Emerging option for high-risk or frail patients
• 🚨 Emergency surgery: Acute severe AR due to endocarditis, aortic dissection, trauma

5️⃣ Supportive / Long-Term Care

• 💊 Manage comorbidities: hypertension, AF, heart failure
• 📅 Serial echocardiography for LV function and aortic root dimensions
• 🦷 Endocarditis prophylaxis before high-risk dental procedures if prosthetic valve
• 🏥 Post-surgical follow-up: anticoagulation if mechanical valve, routine echo surveillance

6️⃣ Prognosis

• Asymptomatic + normal LV function → excellent prognosis with monitoring
• Symptomatic or LV dysfunction → poor prognosis without surgery
• Timely valve replacement restores near-normal life expectancy

📚 References

• ESC/EACTS Guidelines 2017
• AHA/ACC Guidelines 2020
• Otto CM, NEJM 2020: “Aortic Regurgitation and Its Management”
• NICE NG208: Heart Valve Disease (2021)

🧑‍⚕️ Case Examples

• Case 1 (Acute AR - IE): 🦠 35yo man, IV drug user, fever + dyspnoea, collapsing pulse, early diastolic murmur. Echo: vegetations, severe AR. Management: IV antibiotics, urgent cardiothoracic referral.
• Case 2 (Chronic AR - bicuspid valve): 🧬 45yo man, exertional dyspnoea, palpitations, Corrigan pulse. Echo: dilated LV, moderate-severe AR. Management: Surveillance, vasodilators if hypertensive, valve replacement if symptomatic or LV dysfunction develops.
• Case 3 (AR - Marfan’s): 🧑‍⚕️ 28yo, tall, long fingers, palpitations. Echo: dilated root, moderate AR. Management: Beta-blockers to slow root dilation, echo follow-up, surgery when threshold reached.