eMedicine Specialties > Emergency Medicine > Cardiovascular
Aortic Regurgitation
Updated: Aug 19, 2008
Introduction
Background
Aortic regurgitation is the diastolic flow of blood from the aorta into the left ventricle. Regurgitation is due to incompetence of the aortic valve or any disturbance of the valvular apparatus (eg, leaflets, annulus of the aorta) resulting in diastolic flow of blood into the left ventricular chamber.
Pathophysiology
Incompetent closure of the aortic valve can result from intrinsic disease of the cusp, diseases of the aorta, or trauma. Aortic regurgitation may be a chronic disease process or it may occur acutely, presenting as heart failure. The most common cause of chronic aortic regurgitation used to be rheumatic heart disease, but presently it is most commonly bacterial endocarditis. In developed countries, it is caused by dilatation of the ascending aorta (eg, aortic root disease, aortoannular ectasia).
Diastolic reflux through the aortic valve can lead to left ventricular volume overload. The severity of the aortic regurgitation is dependent on the diastolic valve area, the diastolic pressure gradient between the aorta and left ventricle, and the duration of diastole. An increase in systolic stroke volume and low diastolic aortic pressure produces an increased pulse pressure.
Frequency
United States
Rheumatic fever and syphilis used to be major causes of aortic regurgitation, but these diseases have diminished in recent years because of the introduction of new antibiotics.
Mortality/Morbidity
- Three fourths of patients with significant aortic regurgitation survive 5 years after diagnosis; half survive for 10 years. Patients with mild-to-moderate regurgitation survive 10 years in 80-95% of the cases.
- Average survival after onset of congestive heart failure (CHF) is less than 2 years.
- Acute aortic regurgitation is associated with significant morbidity, which can progress from pulmonary edema to refractory heart failure and cardiogenic shock.
Age
Chronic aortic regurgitation often begins in the late 50s and is documented most frequently in patients older than 80 years.
Clinical
History
- General
- The clinical signs of aortic regurgitation are caused by forward and backward flow of blood across the aortic valve, leading to increased stroke volume.
- The degree of regurgitation is determined by the degree of valvular incompetence; left ventricular compliance; and end-ventricular, end-diastolic volume.
- Acute aortic regurgitation: Symptoms are manifestations of cardiovascular collapse.
- Weakness
- Severe dyspnea
- Hypotension
- Angina
- Chronic aortic regurgitation
- Exertional dyspnea
- Nocturnal dyspnea
- Orthopnea
- Diaphoresis
- Abdominal discomfort
- Uncomfortable awareness of heartbeat
- Palpitations
Physical
- The hallmark of aortic regurgitation/insufficiency is a high-pitched decrescendo diastolic murmur at the left sternal border after the second heart sound.
- Acute aortic regurgitation
- Patients who have CHF or shock associated with severe aortic regurgitation often appear gravely ill.
- Tachycardia
- Peripheral vasoconstriction
- Cyanosis
- Pulmonary edema
- Arterial pulsus alternans; normal left ventricular impulse
- Early diastolic murmur (lower pitched and shorter than in chronic aortic regurgitation) may be present. An Austin-Flint murmur, which is caused by the regurgitant flow causing vibration of the mitral apparatus, is lower pitched and short in duration. The decrescendo diastolic murmur is heard best with the patient leaning forward in full expiration in a quiet room. It is the cardiac murmur most commonly missed.
- A murmur at the right sternal border is associated more often with dissection than any other cause of aortic regurgitation.
- Chronic aortic regurgitation
- All auscultatory phenomena indicate vasodilatation of peripheral circulation.
- Hyperdynamic apical impulse displaced laterally and inferiorly may be associated with an ejection click.
- Decrescendo diastolic murmur is heard best while the patient is leaning forward on deep expiration.
- Apical middiastolic rumble
- Austin-Flint murmur
- Pulsus bisferiens; increased pulse pressure; visible, forceful, and bounding peripheral pulses (water hammer)
- Corrigan pulse - Quickly collapsing pulses
- Musset sign - Bobbing of the head
- Quincke sign - Capillary pulsations of the nail bed
- Muller sign - Pulsations of the uvula
- Hill sign - Systolic pressure in lower extremity greater than systolic pressure in upper extremity by at least 100 mm Hg
- Traube sign - Loud systolic sound over femoral arteries
- Duroziez sign - Systolic-diastolic murmur produced by compression of femoral artery with a stethoscope
Causes
- Multiple causes of this valvular abnormality are known, including connective tissue disease and anatomic abnormalities. Acute aortic regurgitation is usually due to aortic dissection, bacterial endocarditis, or trauma, which may be either penetrating or blunt.
- Acute aortic regurgitation
- Rheumatic
- Infective endocarditis
- Ruptured sinus of Valsalva
- Trauma, prosthetic valve surgery
- Aortic dissection, laceration of the aorta
- Chronic aortic regurgitation
- Rheumatic
- Syphilis
- Aortitis (ie, Takayasu disease)
- Marfan syndrome
- Osteogenesis imperfecta
- Bicuspid aortic valve, defect of the interventricular septum or sinus of Valsalva
- Ankylosing spondylitis
- Reiter syndrome
- Rheumatoid arthritis
- Systemic lupus erythematosus
- Hypertension
- Infective endocarditis
More on Aortic Regurgitation |
 Overview: Aortic Regurgitation |
| Differential Diagnoses & Workup: Aortic Regurgitation |
| Treatment & Medication: Aortic Regurgitation |
| Follow-up: Aortic Regurgitation |
| References |
| Next Page » |
References
Babu AN, Kymes SM, Carpenter Fryer SM. Eponyms and the diagnosis of aortic regurgitation: what says the evidence?. Ann Intern Med. May 6 2003;138(9):736-42. [Medline].
Braunwald E. Heart Disease: A Textbook of Cardiovascular Medicine. 3rd ed. Philadelphia, Pa: Saunders; 1988.
Giuliani E. Cardiology: Fundamentals and Practice. 2nd ed. Philadelphia, Pa: Mosby Year Book; 1991.
Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. Feb 16 2000;283(7):897-903. [Medline].
Hwang MS, Chu JJ, Su WJ. Natural history and risk stratification of discrete subaortic stenosis in children: an echocardiographic study. J Formos Med Assoc. Jan 2004;103(1):17-22. [Medline].
Kloner R. The Guide to Cardiology. 2nd ed. New York: Le Jacq Communications; 1990.
Tops LF, Kapadia SR, Tuzcu EM, Vahanian A, Alfieri O, Webb JG, et al. Percutaneous valve procedures: an update. Curr Probl Cardiol. Aug 2008;33(8):417-57. [Medline].
Saura D, Peñafiel P, Martínez J, de la Morena G, García-Alberola A, Soria F, et al. [The frequency of systolic aortic regurgitation and its relationship to heart failure in a consecutive series of patients]. Rev Esp Cardiol. Jul 2008;61(7):771-4. [Medline].
Sambola A, Tornos P, Ferreira-Gonzalez I, Evangelista A. Prognostic value of preoperative indexed end-systolic left ventricle diameter in the outcome after surgery in patients with chronic aortic regurgitation. Am Heart J. Jun 2008;155(6):1114-20. [Medline].
Further Reading
Keywords
aortic regurgitation, aortic insufficiency, aortic valve, aortic valve regurgitation, Corrigan disease, Corrigan's disease, aortic valve incompetence
