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Pediatric Aortic Valve Insufficiency Clinical Presentation

  • Author: Mohsen Saidinejad, MD, MPH, MBA; Chief Editor: Stuart Berger, MD  more...
 
Updated: Jan 04, 2016
 

History

Presenting symptoms in aortic valve insufficiency include the following:

  • Chronic severe aortic valve insufficiency
    • Gradual enlargement of the left ventricle (LV) and gradual increase of stroke volume in most cases
    • No symptoms for many years in most patients with chronic aortic valve insufficiency
    • No symptoms for decades in most patients with chronic moderate aortic valve insufficiency
    • Exertional dyspnea (common)
    • Orthopnea (common)
    • Paroxysmal nocturnal dyspnea (common)
    • Angina pectoris (less common)
    • Abdominal discomfort (less common)
    • Syncope (rare)
    • Nocturnal angina with diaphoresis (rare)
  • Causes of symptoms in chronic severe aortic valve insufficiency
    • The onset of myocardial ischemia and diastolic dysfunction
    • Splanchnic ischemia, which may cause abdominal discomfort
  • Symptoms associated with acute severe aortic valve insufficiency
    • Chest discomfort
    • Dyspnea
    • Hypotension
    • Uncomfortable awareness of heartbeat/palpitations
    • Chest pain
    • Sudden cardiovascular collapse
  • Cause of symptoms in acute severe aortic valve insufficiency
    • Sudden drop in coronary driving pressure
    • Increased filling pressure of the LV
    • Increased left atrial pressure
    • Low cardiac output
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Physical

Physical examination findings can be associated with the signs and symptoms of various degrees of severity of insufficiency and with the status of LV compensation. These may include physical findings of widening of pulse pressure or volume overload. In chronic aortic valve insufficiency, systolic pressures are abnormally elevated and diastolic pressures are abnormally low, which may indicate the extent of aortic valve insufficiency.

Coexisting cardiac pathology, such as a ventricular septal defect or aortic stenosis, may also be revealed during physical examination.

  • Physical findings in chronic severe aortic valve insufficiency
    • Water-hammer pulse - Bounding radial pulse with elevation of the patient's arm
    • Corrigan pulse - A quick filling and collapse of carotid pulse
    • de Musset sign - Head bobbing with each systole
    • Bisferiens pulse - Characterized by 2 systolic peaks of equal or unequal magnitudes separated by a midsystolic trough; usually detected well in the carotid artery, but noted better in the brachial and femoral pulses in severe chronic aortic valve insufficiency
    • Traube sign - Bounding pistol shot–like femoral artery pulse during systole and diastole
    • Müller sign - Pulsations of the uvula during systole
    • Duroziez sign - Murmur heard over femoral artery when compressed; heard during systole when the femoral artery is compressed proximally and heard during diastole when the femoral artery is compressed distally
    • Quincke sign - Pulsations of the nail beds with systole, when the nail is distally compressed
    • Hill sign - A greater than 40 mm Hg elevation of the popliteal systolic pressure over that of the brachial systolic pressure
  • Physical findings in chronic aortic valve insufficiency associated with increased stroke volume
    • Displacement of the point of maximal impulse inferiorly and laterally, consistent with the volume overload and increased LV chamber size
    • Hyperdynamic apical impulse
    • Diastolic thrill, consistent with rapid forceful ventricular emptying
    • Systolic thrill over suprasternal notch or carotid arteries, consistent with increased stroke volume
  • Auscultatory findings in chronic severe aortic valve insufficiency
    • Soft S1
    • S2 abnormalities, which may include absent S2, single S2, or paradoxical splitting of S2
      • Soft or absent A2 portion of S2 can be caused by incomplete or abnormal closure of the aortic valve.
      • Absent P2 portion of S2 may be caused by the murmur of AI during the early diastole.
      • Paradoxical splitting of S2 can be caused by delayed closure of the aortic valve because of increased preload volume.
    • Systolic murmur - Caused by forceful ejection of overloaded volume from the LV, which results in aortic distension
    • S3 - Can be heard when filling of the LV continues through an already expanded and stretched LV; may suggest an extremely high-end systolic volume of the LV and may be an early sign of impeding LV failure and severe AR
    • Diastolic murmur
  • Quality of the murmur of chronic aortic valve insufficiency
    • High frequency
    • Begins immediately after A2
    • Best heard with patient sitting up or leaning forward (increases the setting of preload and volume return to the heart, accentuates the murmur of aortic valve insufficiency)
    • Best heard with deep expiration
    • Holodiastolic decrescendo (signifies severe insufficiency)
  • Auscultatory differentiation between chronic severe and chronic mild aortic valve insufficiency
    • Intensity and duration of the murmur correlate with the amount of volume overload and stroke volume ejected from the LV to the aorta.
    • A murmur that is confined to the early part of diastole correlates with mild AR. This murmur is also high pitched.
    • A murmur that extends through diastole correlates with severe aortic valve insufficiency.
    • A musical-type murmur may be related to a perforated aortic valve cusp.
  • Determining where the aortic valve insufficiency murmur is best heard
    • A murmur that is best heard at the left sternal border at the third and fourth intercostal spaces suggests a primary valvular disease.
    • A murmur that is best heard along the right sternal border suggests proximal aortic root dilatation.
    • An Austin Flint murmur is a mid-diastolic to late-diastolic rumble, which is best heard at the apex.
  • The Austin Flint murmur
    • This mid-diastolic to late-diastolic murmur is present when a surge of flow from the left atrium to the LV is counteracted by the regurgitant flow from the aorta to the LV as it courses back into the mitral valve. The regurgitant flow causes constriction of the mitral opening and accentuates the rumble of the forward flow from the left atrium through the mitral valve.
    • The Austin Flint murmur is similar to the murmur of mitral stenosis. The difference is that S1 is not as loud in aortic valve insufficiency as it is in mitral stenosis.
    • Onset, duration, and termination of the Austin Flint murmur are related to the amount of LV volume overload and the end-diastolic pressure in the LV chamber. In the most severe form of increased end-diastolic pressure, the murmur is heard in early to mid diastole.
    • The Austin Flint murmur may be graded 1-4, depending on the ejection fraction and stroke volume. The murmur can be transmitted upward to the carotid vessels.
  • Certain maneuvers that can alter the intensity of the murmur in chronic aortic valve insufficiency
    • Sitting up or leaning forward causes increased volume overload and increased LV end-diastolic pressure; therefore, it increases the intensity of the murmur.
    • Straining, Valsalva maneuver, and hypotension decrease the intensity of the murmur.
  • Physical findings in acute severe aortic valve insufficiency
    • Severe cyanosis
    • Tachycardia
    • Severe dyspnea indicating pulmonary congestion and LV failure
    • Edema
    • Limited peripheral manifestations
    • No significant widening of pulse pressure
    • May relate to acute mitral valve regurgitation and premature closure of mitral valve
    • Pulmonary hypertension with S3, S4, and loud P2
    • Low-pitched short early diastolic murmur: In extremely severe aortic valve insufficiency, when LV decompensation occurs, a significant part of the murmur is diminished as an equalization of pressure occurs between the aorta and the LV in the latter part of diastole.
    • Shortened (or absent) Austin Flint murmur, with no presystolic component because of premature closure of the mitral valve during diastole
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Causes

See the list below:

  • Causes of aortic valve insufficiency include congenital malformations of the aortic valves and diseases of the aortic valves and root.
  • See Pathophysiology for further discussion of causes.
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Contributor Information and Disclosures
Author

Mohsen Saidinejad, MD, MPH, MBA Assistant Professor of Pediatrics and Emergency Medicine, George Washington University School of Medicine and Health Sciences; Attending Physician, Department of Pediatric Emergency Medicine, Children's National Medical Center

Mohsen Saidinejad, MD, MPH, MBA is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians, American Public Health Association

Disclosure: Nothing to disclose.

Coauthor(s)

Russell R Cross, MD, FACC Associate Clinical Professor of Pediatrics, George Washington University Medical Center; Attending Cardiologist, Co-Director of Cardiac MRI, Division of Cardiology, Children's National Medical Center

Russell R Cross, MD, FACC is a member of the following medical societies: American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Magnetic Resonance

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Alvin J Chin, MD Emeritus Professor of Pediatrics, University of Pennsylvania School of Medicine

Alvin J Chin, MD is a member of the following medical societies: American Association for the Advancement of Science, Society for Developmental Biology, American Heart Association

Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD Medical Director of The Heart Center, Children's Hospital of Wisconsin; Associate Professor, Department of Pediatrics, Section of Pediatric Cardiology, Medical College of Wisconsin

Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, Society for Cardiovascular Angiography and Interventions

Disclosure: Nothing to disclose.

Additional Contributors

Christopher Johnsrude, MD, MS Chief, Division of Pediatric Cardiology, University of Louisville School of Medicine; Director, Congenital Heart Center, Kosair Children's Hospital

Christopher Johnsrude, MD, MS is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of eMedicine gratefully acknowledge the contributions of Samuel Ritter, MD, to the original writing and development of this article.

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Aortic regurgitation. Color Doppler echocardiogram.
 
 
 
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