1. Aortic regurgitation
Dr Husain Tayib

2. Aortic regurgitation

3. Aortic regurgitation Etiology _Acquired
*Any conditions resulting in incompetent aortic leaflets
_Congenital
Bicuspid AV
_Aortopathy
Cystic medial necrosis
Collagen disorders (.Marfan Syn.]
Ehler-Danlos
Osteogenesis imperfecta
Pseudoxanthoma elasticum
_Acquired
* Rheumatic heart disease
*Dilated aorta [ hyperte.]
*Degenerative
*Connective tissue disorder
_ Ankylosing spondylitis, _Rheumatoid arthritis, _Reiter’s syndrome, _Giant-cell arteritis )
*Syphilis (chronic aortitis)
*Acute AR:
, _Infective endocarditis, _Trauma
_Dissecting aneurysm

4. Aortic regurgitation
Aortic Dissection
Bicuspid AV
Marfan syndrome

5. Aortic regurgitation Pathophysiology Chronic AR
Elevated LV end-diastolic pressure and volume
Dilatation and eccentric hypertrophy of the LV
Increased stroke volume
Left ventricular EF  normal
Gradually LV preload and afterload both increased
Ultimately, adaptive measures fail.
LV function deteriorates
End-diastolic volume rises further (the largest heart)  Myocardial ischemia
Decline in forward stroke volume and EF
LVDOL…. LV dilatation …. Increased SV ….. Wide PP…..LVH …Dilated LA …. Increased LVEDP……LAP rise …..
Pulmonary congestion …. PH …. RVH
……RVF

6. _Dyspnea, orthopnea, PND
Aortic regurgitation
Symptoms
Mild to moderate AR :
* Often asymptomatic * Palpitation
Severe AR :
_Dyspnea, orthopnea, PND
_Chest pain.
Nocturnal angina >> exertional angina
{ diastolic aortic pressure and increased LVEDP thus  coronary artery diastolic flow}
*With extreme reductions in diastolic pressures {e.g. < 40} may see angina

7. Aortic regurgitation _Durosier’s sign: femoral retrograde bruits
Peripheral Signs
_Durosier’s sign: femoral retrograde bruits
_Traube’s sign: pistol shot femorals
_Hill’s sign:BP Lower extremity >BP Upper extremity by
_> 20 mm Hg - mild AR
_> 40 mm Hg – mod AR
_> 60 mm Hg – severe AR
_Quincke’s sign: capillary pulsation
_Corrigan’s sign: _Water hammer pulse
_Bisferiens pulse (AS/AR > AR)
_De Musset’s sign: systolic head bobbing
_Mueller’s sign: systolic pulsation of uvula

9. Central Signs of Severe
Aortic regurgitation
Central Signs of Severe
Apex:
_Enlarged
_Displaced
_Hyper-dynamicLforcible nonsustained
_Palpable S3
_Austin-Flint murmur
Aortic diastolic murmur
_Length correlates with severity {chronic AR}
_In acute AR murmur shortens as Aortic DP=LVEDP
_In acute AR - mitral pre-closure

10. Aortic regurgitation Physical examination Widened pulse pressure
systolic – diastolic = pulse pressure _ S1 S2 S1
AUSCULTATION
Murmur: high-pitched, blowing, decrescendo diastolic murmur, heard best in the third intercostal space along the left sternal border (holodiastolic in severe AR)
When the murmur is soft, it can be heard best with the diapgm hraof the stethoscope and with the patient sitting up, leaning forward, and with the breath held in forced expiration. 10 10

11. A mid-systolic ejection murmur frequently audible in isolated AR
Flint murmur, a soft, low-pitched, rumbling mid-diastolic murmur probably produced by the diastolic displacement of the anterior leaflet of the mitral valve by the AR stream not due to hemodynamically significant mitral obstruction 11 11

12. Common Murmurs and Timing
Aortic regurgitation
Common Murmurs and Timing
,_Systolic Murmurs
_ Aortic stenosis
_ Mitral insufficiency
_Mitral valve prolapse
_Tricuspid insufficiency
Diastolic Murmurs
_Aortic insufficiency
_Mitral stenosis
S S S1

13. Aortic regurgitation Investigations : *ECG :- LVH + T inversion
*Chest XR :- _ Cadiac dilatation _ Aortic dilatation
_ Pulmonary congestion
*ECHO : _Dilated LV _ Hyperdynamic LV
_Fluttering AML _ Doppler detects reflux
*Cardiac Catheterization :-
_Dilated LV _ AR
_Dilated aortic root

14. Aortic regurgitation
Chest XR PA view

15. Aortic regurgitation
LVH
ECG

16. Aortic regurgitation
CW-doppler AR
AR+AS
CFM AR AR AR

17. Assessing severity of AR
Aortic regurgitation
Assessing severity of AR
*Assess severity by impact on peripheral signs and LV
 peripheral signs =  severity
 LV =  severity S3
Austin –Flint murmer
LVH
radiological cardiomegaly

18. TX: Medical  Surgery BEFORE LV dysfunction
Aortic regurgitation
Natural history :
*Asymptomatic %/Y
Normal LV function {--good prognosis}
_Progression to symptoms or LV dysfunction < 6
_Progression to asymptomatic LV dysfunction < 3.5
_ 5-year survival % < _Sudden death
Abnormal LV function
_Progression to cardiac symptoms
*Symptomatic {poor prognosis
_Mortality >10%
TX: Medical  Surgery BEFORE LV dysfunction
Bonow RO, et al, JACC. 1998;32:1486.

19. Aortic regurgitation Management : * Medical :
_Vasodilator { ACEIs } _ Diuretics for pulmonary congestion
_Prophylaxis against IE _Treatment of underline cause e.g.
IE , Syphilis
*Surgical :
_AV replacement Mechanical or Bioprosthesis
_Aortic root replacement for dilated A root , {e.g. Syphilis ,
Marfan`s syndrome , Dissecting aneurysm }
*EHO indications for AVR : _LVEDD >55 _EF > 55% _FS > 27%

20. Criteria for Aortic Valve Replacement in Chronic Aortic Regurgitation
Symptoms
Congestive heart failure.
Declining exercise tolerance on exercise testing.
Angina
Anatomy, regardless of symptoms:
Left ventricular dysfunction: EF <50%
Progressive left ventricular dilation or decline in EF on serial studies
Severe dilation (echo):
- Left ventricular diastolic dimension >75 mm
- Left ventricular systolic dimension >55 mm
-Aortic root dimension >50 mm

21. Aortic regurgitation
AV-replacement

22. Thank you