🫀 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

Cause	Details
Rheumatic	Leaflet thickening, commissural fusion. Still common in low-resource regions 🌍.
Infective Endocarditis	Valve destruction → acute AR → shock 🚑.
Bicuspid Aortic Valve	Congenital → predisposes to AR & AS 🧬.
Aortic Root Dilatation	Marfan, Ehlers-Danlos, Loeys-Dietz, syphilis, HTN, ageing.
Degenerative	Valve fibrosis/calcification in elderly.
Aortic Dissection (Type A)	Tear near root → acute AR → surgical emergency ⚡.
Trauma	Blunt chest trauma (rare).
Hypertension	Chronic root dilatation worsening regurgitation.

🩺 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, ischemic changes.
Echocardiography: Gold standard. Assess valve, LV size, EF, regurgitant volume via color 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.

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Aortic Regurgitation ✅