Aortic Regurgitation (AR)

What is Aortic Regurgitation (AR) according to the summary?

A valvular heart disease characterized by incomplete closure of the aortic valve leading to the reflux of blood from the aorta into the left ventricle (LV) during diastole. Summary 1

What are the two main categories of causes for Aortic Regurgitation (AR) mentioned in the summary?

AR can be acute (primarily caused by bacterial endocarditis or aortic dissection) or chronic (e.g., due to congenital bicuspid valve or rheumatic fever). Summary / Etiology 2

What is the typical clinical course of acute Aortic Regurgitation (AR) according to the summary?

Acute AR often leads to rapid deterioration of LV function with subsequent pulmonary edema and cardiac decompensation. Summary / Clinical 3

How does the clinical course of chronic Aortic Regurgitation (AR) differ from acute AR, according to the summary?

Chronic AR may remain compensated for a long period, becoming symptomatic only when left heart failure develops. Summary / Clinical 4

What auscultatory findings are characteristic of Aortic Regurgitation (AR) according to the summary?

Auscultation reveals an S3 and a high-pitched, decrescendo early diastolic murmur. Summary / Clinical 5

What finding related to pulse pressure is characteristic of Aortic Regurgitation (AR) according to the summary?

A characteristic diagnostic finding is widened pulse pressure. Summary / Clinical 6

What is the most important diagnostic tool for confirming Aortic Regurgitation (AR) according to the summary?

Echocardiography is the most important diagnostic tool, both for confirming the diagnosis and determining severity. Summary / Diagnosis 7

How is symptomatic Aortic Regurgitation (AR) typically managed according to the summary?

Symptomatic patients or those with severely reduced LV function require surgical intervention, most commonly aortic valve replacement. Summary / Treatment 8

List two primary causes of acute Aortic Regurgitation (AR).

Infective endocarditis, aortic dissection (ascending aorta), chest trauma, or iatrogenic complications. (Any 2) Etiology 9

What is the most common cause of chronic Aortic Regurgitation (AR) in young adults in high-income countries?

Congenital bicuspid aortic valve. Etiology 10

What is the most common cause of chronic Aortic Regurgitation (AR) in older patients in high-income countries?

Calcific aortic valve disease. Etiology 11

What is the most common cause of chronic Aortic Regurgitation (AR) in lower-income countries?

Rheumatic heart disease. Etiology 12

Besides valvular defects, what other category of conditions can cause chronic Aortic Regurgitation (AR)?

Aortic dilatation (e.g., due to connective tissue disorders like Marfan, chronic hypertension, aortitis, thoracic aortic aneurysm). Etiology 13

How does Aortic Regurgitation (AR) affect systolic and diastolic blood pressure?

AR leads to increased systolic blood pressure and decreased diastolic blood pressure. Pathophysiology 14

What effect does Aortic Regurgitation (AR) have on pulse pressure?

AR leads to a widened pulse pressure. Pathophysiology 15

Why does acute Aortic Regurgitation (AR) often lead rapidly to pulmonary edema?

Because the LV cannot sufficiently dilate quickly, LV end-diastolic pressure increases rapidly, transmitting pressure backward into the pulmonary circulation. Pathophysiology 16

What compensatory mechanism occurs initially in chronic Aortic Regurgitation (AR)?

An increase in stroke volume initially maintains adequate cardiac output despite regurgitation (compensated heart failure). Pathophysiology 17

What type of hypertrophy and remodeling occurs over time in chronic Aortic Regurgitation (AR)?

Increased LV end-diastolic volume leads to LV enlargement and eccentric hypertrophy of the myocardium. Pathophysiology 18

What are the typical signs and symptoms of acute Aortic Regurgitation (AR)?

Sudden severe dyspnea, rapid cardiac decompensation (heart failure), pulmonary edema, and potentially symptoms of the underlying cause (fever, chest pain). Clinical Features 19

What are the characteristic auscultation findings in acute Aortic Regurgitation (AR)?

A soft S1 sound and a soft and short early diastolic murmur. Clinical Features 20

For how long might patients with chronic Aortic Regurgitation (AR) remain asymptomatic?

Chronic AR may be asymptomatic for up to decades despite progressive LV dilation. Clinical Features 21

What is the "water hammer pulse" associated with chronic Aortic Regurgitation (AR)?

A peripheral arterial pulse characterized by rapid upstroke and downstroke due to widened pulse pressure. Clinical Features 22

What is the Corrigan pulse associated with chronic Aortic Regurgitation (AR)?

A pulse of the carotid arteries characterized by rapid upstroke and downstroke. Clinical Features 23

What is the Traube sign associated with chronic Aortic Regurgitation (AR)?

Pistol shot-like sounds heard over the femoral artery on auscultation. Clinical Features 24

What is the Duroziez sign associated with chronic Aortic Regurgitation (AR)?

A to-and-fro bruit heard over the femoral artery when slight pressure is applied with a stethoscope. Clinical Features 25

What is the Quincke sign associated with chronic Aortic Regurgitation (AR)?

A visible capillary pulse seen when pressure is applied to the tip of a fingernail. Clinical Features 26

What is the De Musset sign associated with chronic Aortic Regurgitation (AR)?

Rhythmic nodding or bobbing of the head in synchrony with heartbeats. Clinical Features 27

What symptoms indicate developing left heart failure in chronic Aortic Regurgitation (AR)?

Exertional dyspnea, angina, orthopnea, easy fatigability, or syncope. Clinical Features 28

How might the point of maximal impulse (PMI) be described in chronic Aortic Regurgitation (AR)?

The PMI may be diffuse, hyperdynamic, and displaced inferolaterally. Clinical Features 29

Describe the classic diastolic murmur of chronic Aortic Regurgitation (AR).

A high-pitched, blowing, decrescendo early diastolic murmur. Clinical Features 30

Where is the murmur of chronic Aortic Regurgitation (AR) best heard if due to valvular disease?

Heard best in the left third and fourth intercostal spaces and along the left sternal border (Erb point). Clinical Features 31

Where is the murmur of chronic Aortic Regurgitation (AR) best heard if due to aortic root disease?

Heard best along the right sternal border. Clinical Features 32

What maneuvers worsen the diastolic murmur of Aortic Regurgitation (AR)?

Squatting and handgrip (increase afterload). Clinical Features 33

What is the Austin Flint murmur sometimes heard in Aortic Regurgitation (AR)?

A rumbling, low-pitched, mid-diastolic or presystolic murmur heard best at the apex, caused by the regurgitant jet striking the anterior mitral leaflet. Clinical Features 34

What is the modality of choice for the initial assessment of suspected Aortic Regurgitation (AR)?

Transthoracic echocardiography (TTE). Diagnosis 35

When is Transesophageal echocardiography (TEE) indicated for Aortic Regurgitation (AR)?

For moderate to severe AR if TTE findings are equivocal, or for preoperative planning. Diagnosis 36

What general findings on echocardiography support an Aortic Regurgitation (AR) diagnosis?

Abnormal aortic valve leaflets, fluttering of the anterior mitral valve leaflet, regurgitant AR jet on Doppler, and potentially a dilated aorta. Diagnosis 37

What echo findings are specific to acute Aortic Regurgitation (AR)?

Reduced cardiac output, elevated LV end-diastolic pressure, early mitral valve closing, rapid equilibration of aortic and LV pressure. Diagnosis 38

What echo finding is specific to chronic Aortic Regurgitation (AR)?

Increased LV size and volume. Diagnosis 39

What findings on ECG might suggest chronic Aortic Regurgitation (AR)?

ECG signs of LVH, ST-segment depression, and T-wave inversion in leads I, aVL, V5, and V6. Diagnosis 40

What might a chest x-ray show in acute Aortic Regurgitation (AR)?

Often a normal heart silhouette, but with x-ray signs of pulmonary congestion or edema. Diagnosis 41

What might a chest x-ray show in chronic Aortic Regurgitation (AR)?

X-ray signs of LVH, an enlarged cardiac silhouette, and possibly a prominent aortic root/arch. Diagnosis 42

What is the required management for severe acute Aortic Regurgitation (AR)?

Severe acute AR requires surgical treatment (typically valve replacement) as soon as possible. Treatment 43

Why is Intra-aortic balloon pump (IABP) contraindicated in acute severe Aortic Regurgitation (AR)?

IABP increases the regurgitant volume and worsens the condition. Treatment 44

What are the primary indications for surgery in chronic severe Aortic Regurgitation (AR)?

Presence of symptoms OR asymptomatic severe AR with reduced LVEF (≤ 55%) or significant LV dilation (LVESD > 50 mm), or undergoing cardiac surgery for other reasons. Treatment 45

What is the standard surgical procedure for chronic Aortic Regurgitation (AR)?

Surgical aortic valve replacement is the standard procedure. Treatment 46

What is the goal of medical management in chronic Aortic Regurgitation (AR)?

Screen/treat cardiac risk factors and manage comorbidities like hypertension (target SBP < 140 mmHg) and heart failure. (No drugs influence disease progression). Treatment 47

How are asymptomatic patients with chronic Aortic Regurgitation (AR) monitored?

Monitor with serial echocardiography to identify possible progression and indications for intervention. Treatment 48

What is the annual rate of progression to symptoms or LV dysfunction in asymptomatic AR patients with normal LVEF?

Progression occurs at a rate of < 6% per year. Prognosis 49

What is the annual rate of progression to symptoms in asymptomatic AR patients with decreased LVEF?

Progression occurs at a rate of > 25% per year. Prognosis 50

What is the approximate annual mortality rate for symptomatic patients with Aortic Regurgitation (AR)?

The mortality rate is > 10% per year. Prognosis 51