History
Acute aortic regurgitation
The typical presentation of severe acute AR includes sudden, severe shortness of breath; rapidly developing heart failure; and chest pain if myocardial perfusion pressure is decreased or an aortic dissection is present. [5]
Chronic aortic regurgitation
Patients with chronic AR often have a long-standing asymptomatic period that may last for several years. A compensatory tachycardia may develop to maintain a large forward stroke volume, leading to a decreased diastolic filling period. As a result, patients may be asymptomatic even with exercise. Over time, however, chronic volume overload leads to LV dysfunction as the LV dilates. Significant deterioration of LV function may begin prior to the development of symptoms in up to 25% of patients, highlighting the importance of periodic echocardiographic surveillance.
Among patients with asymptomatic LV dysfunction, more than 25% of them develop symptoms within 1 year. Once symptoms arise, cardiac function usually worsens more rapidly and mortality may exceed 10% per year.
Symptoms of severe chronic AR include the following:
Palpitations - Often described as the sensation of having forceful heart beats, due to widened pulse pressure with hyperdynamic circulation
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Uncomfortable awareness of the heartbeat
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Shortness of breath - May not worsen with exertion in the early stages due to compensatory tachycardia with shortened diastole
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Chest pain - Occurs if increased LV end-diastolic pressure compromises coronary perfusion pressure gradients
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Sudden cardiac death - This is uncommon (< 0.2% per year) in asymptomatic patients with preserved LV function
Physical Examination
Many classical physical examination findings have been described in patients with severe chronic AR. However, these findings may be only minimally present (if at all) in patients with severe acute AR.
Acute aortic regurgitation
Cases of acute AR may be fulminant and lead to cardiogenic shock; patients who have CHF or shock associated with severe AR often appear gravely ill. Other symptoms of acute AR include the following:
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Tachycardia
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Peripheral vasoconstriction
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Cyanosis
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Pulmonary edema
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Arterial pulsus alternans; normal LV impulse
Early diastolic murmur (lower pitched and shorter than in chronic AR) 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 one of the cardiac murmurs most commonly missed.
A murmur at the right sternal border is associated more often with aortic dissection than it is with any other cause of AR.
Chronic aortic regurgitation
Manifestations of severe chronic AR are often the result of widened pulse pressure (ie, an exaggerated difference between systolic and diastolic blood pressure) because (1) elevated stroke volume exists during systole and (2) the incompetent aortic valve allows the diastolic pressure within the aorta to fall significantly.
Diastolic pressures are often lower than 60 mm Hg, with pulse pressures often exceeding 100 mm Hg, although younger patients with more compliant vessels may have a less widened pulse pressure. Associated physical examination findings include the following:
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Becker sign - Visible systolic pulsations of the retinal arterioles
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Corrigan pulse ("water-hammer" pulse) - Abrupt distention and quick collapse on palpation of the peripheral arterial pulse
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de Musset sign - Bobbing motion of the patient's head with each heartbeat
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Hill sign - Popliteal cuff systolic blood pressure 40 mm Hg higher than brachial cuff systolic blood pressure
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Duroziez sign - Systolic murmur over the femoral artery with proximal compression of the artery, and diastolic murmur over the femoral artery with distal compression of the artery
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Müller sign - Visible systolic pulsations of the uvula
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Quincke sign - Visible pulsations of the fingernail bed with light compression of the fingernail
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Traube sign ("pistol-shot" pulse) - Booming systolic and diastolic sounds auscultated over the femoral artery
On palpation, the point of maximal impulse may be diffuse or hyperdynamic but is often displaced inferiorly and toward the axilla. Peripheral pulses are prominent or bounding. Auscultation may reveal an S3 gallop if LV dysfunction is present.
The murmur of AR occurs in diastole, usually as a high-pitched sound that is loudest at the left sternal border. The duration of the murmur correlates better with the severity of AR than does the loudness of the murmur. A functional systolic flow murmur may also be present because of increased stroke volume, although concurrent aortic stenosis may also be present. [5]
An Austin-Flint murmur may be present at the cardiac apex in severe AR; it is a low-pitched, mid-diastolic rumbling murmur due to blood jets from the AR striking the anterior leaflet of the mitral valve, which results in premature closure of the mitral leaflets.
In many cases, physical examination also reveals findings relating to the underlying cause of AR. For example, there may be various embolic phenomena in patients with AR due to infective endocarditis, or the patient may have skeletal features suggestive of Marfan syndrome or a spondyloarthropathy if AR is due to these conditions.
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Aortic regurgitation. Color Doppler echocardiogram.
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Aortic regurgitation. Doppler echocardiographic signals may be reviewed to evaluate the severity of disease.
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Aortic regurgitation. Two-dimensional (2D) color Doppler echocardiography.
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Aortic regurgitation. Aortic-root angiography shows regurgitation of contrast material into the left ventricle (LV).
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Aortic regurgitation. Chest radiograph in a patient with aortic dissection and acute aortic regurgitation shows a cardiac silhouette of essentially normal dimension.
Tables
LVESD (mm) |
LVEDD (mm) |
Dimensions |
Clinical Evaluation |
Echocardiogram |
< 45 |
< 60 |
Stable |
6-12 months |
12 months |
< 45 |
< 60 |
Increasing |
3 months |
3 months |
45-50 |
60-70 |
Stable |
6 months |
12 months |
45-50 |
60-70 |
Increasing |
3 months |
3 months |
50-55 |
70-75 |
Stable |
6 months |
6 months |
50-55 |
70-75 |
Increasing |
3 months |
3 months |
>55 |
>75 |
|
Surgery recommended |
|
Aortic valve replacement (AVR) indications Note: STS guidelines recommend “valve replacement or valve repair” |
AHA/ACC (2014) [4] |
ESC/EACTS (2012) [43] |
STS (2013) [9] |
Symptomatic severe AR |
Class I |
Class I |
Class I |
Asymptomatic chronic severe AR and left ventricular ejection fraction (LVEF) ≤50% |
Class I |
Class I |
Class I |
Severe AR when undergoing other cardiac surgery |
Class I |
Class I |
Class I |
Asymptomatic severe AR with normal LVEF (≥50%) but with severe LV dilation (LVESD >50mm) |
Class IIa-Reasonable |
Class IIa-Reasonable |
Class IIa-Reasonable |
Moderate AR when undergoing other cardiac surgery |
Class IIa-Reasonable |
Class IIb-Consider |
|
Asymptomatic severe AR and normal LVEF (≥50%) but with progressive severe LV dilation (LVEDD >65 mm) if surgical risk is low |
Class IIb-Consider |
Class IIa-Reasonable |
Class IIb-Consider |
Not indicated for asymptomatic patients with mild, moderate, or severe AR and normal LV systolic function at rest when the degree of LV dilation is not moderate or severe |
Class III |
