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Aortic Regurgitation (Incompetence)

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About

At the end of systole ejected blood refluxes back into LV during diastole due to failure of the valve to prevent it.
The aortic root dilates and there is LV volume overload and this exacerbates aortic regurgitation

Anatomy

The aortic valve has three leaflets, each having a cusp or cup-like configuration.
These are known as the left coronary cusp (L), the right coronary cusp (R) and the posterior non-coronary cusp (N).
Just above the aortic valves there are anatomic dilations of the ascending aorta, also known as the sinus of Valsalva

Aetiology

The Left ventricle becomes dilated and volume overloaded due to reflux of blood during diastole.
Valve or ring valve ring damage and dilation further impairs valve function.
The regurgitant jet may impair coronary perfusion

Causes

Cause	Details
Rheumatic Heart Disease	Post rheumatic fever, scarring and deformation of the AV leaflets, leading to their inability to close properly. Seen in those from Developing countries where RF is prevalent.
Infective Endocarditis	Causes destruction of the aortic valve leaflets, acute or chronic AR. May result in perforation, leaflet rupture, or vegetations that prevent proper closure of the valve.
Bicuspid Aortic Valve	AV has two leaflets instead of the normal three. Early degeneration, resulting in aortic regurgitation, often in conjunction with AS.
Aortic Root Dilation	Dilation of the aortic root, the portion of the aorta closest to the heart, can lead to aortic regurgitation by pulling the aortic valve leaflets apart, preventing them from closing properly. Causes include hypertension, connective tissue disorders like Marfan syndrome, and idiopathic aortic root dilation.
Degenerative Valve Disease	Age-related degenerative changes in the aortic valve, such as calcification and fibrosis, can lead to valve incompetence and aortic regurgitation. This is more common in older adults and can occur alongside aortic stenosis.
Type A Aortic dissection	A life-threatening condition where a tear in the inner layer of the aorta allows blood to flow between the layers of the aortic wall. This can damage the aortic valve or cause aortic root dilation, leading to acute AR. Chest pain + EDM. Needs urgent imaging and management.
Connective Tissue Disorders	Connective tissue disorders like Marfan syndrome, Rheumatoid arthritis, Osteogenesis imperfecta Ehlers-Danlos syndrome (Type IV), Ankylosing spondylitis /Reiter's syndrome and Loeys-Dietz syndrome can weaken the aortic wall and valve, leading to aortic root dilation and aortic regurgitation.
Trauma	Blunt chest trauma can damage the aortic valve or the aorta itself, leading to acute aortic regurgitation. This is a rare but serious cause that requires immediate attention.

Clinical

Acute pulmonary oedema - SOB, Tachycardia, S3, Basal creps, Raised JVP
Palpitations, Dyspnoea, Widened pulse pressure (SBP-DBP)
Angina due to regurgitant diastolic jet and increased MVO₂ demand
High pitched early diastolic murmur at LSE louder with patient sitting forwards in expiration
Dynamic "volume overloaded" apex beat shifted to the left and downwards
In acute AR the murmur may become inaudible and be replaced by a third heart sound. The patient needs urgent surgical referral.

Eponymous signs

Austin flint mid diastolic murmur - turbulence at AMVL
Quincke's sign - visible pulsations in nail bed
Corrigan's sign - visible carotid pulsations
De Musset's - head nodding with pulse
Durozier's sign - diastolic murmur distal to pressure on femoral
Muller's sign - visible pulsation of uvula
Gerhard's sign - systolic pulsations of the spleen
Landolfi's sign: systolic contraction and diastolic dilation of the pupil and results from the large stroke volume

Famous Eponymous Signs

Clinical Sign	Description
Corrigan's Pulse (Water-Hammer Pulse)	A bounding and forceful pulse with rapid upstroke and quick collapse, reflecting the high stroke volume and regurgitant flow.
Quincke's Sign	Capillary pulsations visible in the nail bed when light pressure is applied, indicative of a wide pulse pressure.
Muller's Sign	Pulsation of the uvula seen during systole, due to increased stroke volume and wide pulse pressure.
Duroziez's Sign	A systolic and diastolic murmur heard over the femoral artery when it is lightly compressed with a stethoscope, associated with significant aortic regurgitation.
de Musset's Sign	Head nodding that occurs in time with the heartbeat, caused by the forceful ejection of blood in systole and regurgitation in diastole.
Hill's Sign	Popliteal systolic blood pressure that is at least 20 mmHg higher than brachial systolic pressure, indicating severe aortic regurgitation.
Traube's Sign	A "pistol-shot" sound heard over the femoral arteries, associated with a large stroke volume and wide pulse pressure.
Becker's Sign	Visible pulsations of the retinal arteries, reflecting the increased stroke volume and wide pulse pressure.

Investigations

FBC,WCC, CRP elevated - think endocarditis
U&E, LFT, Glucose, Lipids
CXR - cardiomegaly and dilated ascending aorta. LVF may develop.
ECG - LVH + strain + LAD
Echocardiogram: colour doppler confirms regurgitant flow and allows measurement of aortic valve root and LV function. Echocardiography (TTE/TOE |TEE) is the key examination to describe valve anatomy, quantify aortic regurgitation, evaluate its mechanisms, define the morphology of the aorta and determine the feasibility of valve-sparing aortic surgery or valve repair.
Cardiac catheter: LV ventriculogram (aortogram) shows degree of reflux of injected contrast

Complications

Pulmonary oedema
Congestive cardiac failure
Endocarditis, Arrhythmias
Type A Aortic Dissection

Management

Treatment Option	Details
Medical Management	Vasodilators: Diuretics, ACEi, ARBs, or nifedipine can reduce afterload, decreasing the severity of regurgitation and improving symptoms. Used to treat LVF/CCF. Diuretics: Manage pulmonary congestion in patients with heart failure. Beta-blockers: Useful in patients with connective tissue disorders to reduce the rate of aortic root dilation. Monitoring: Regular echocardiography every 1-2 years to assess the progression of the disease and the timing of surgical intervention.
Surgical Aortic Valve Replacement (SAVR)	Symptomatic patients with severe AR or for asymptomatic patients with evidence of LV dysfunction (ejection fraction <50%) or significant LV dilation. Surgery is indicated in all patients with Marfan syndrome and a maximal aortic diameter > 50 mm. Replace regurgitant valve with a mechanical or bioprosthetic valve. Mechanical valves require lifelong anticoagulation, while bioprosthetic valves generally do not but may have a shorter lifespan.
Transcatheter Aortic Valve Replacement (TAVR)	TAVR is a less invasive option and used in high-risk or unsuitable candidates for surgery. It involves the placement of a new valve within the existing aortic valve via catheterization. TAVR is particularly considered for patients with severe aortic regurgitation who are not ideal candidates for open-heart surgery.
Aortic Root Surgery	In patients with AR due to aortic root dilation (e.g., Marfan syndrome), aortic root surgery, including root replacement or repair, may be indicated. Often performed in conjunction with valve replacement or repair.
Management of Comorbidities	Control of hypertension is crucial. Manage heart failure. Start diuretics and beta-blockers. Patients with connective tissue disorders may require additional monitoring and treatment to prevent complications.
Lifestyle Modifications	Modest regular exercise but avoid activities that could significantly increase blood pressure or strain the heart. Dietary modifications, including reduced salt intake, can help manage blood pressure and fluid retention. Smoking cessation and maintaining a healthy weight are important for overall cardiovascular health.

Indications for surgery

Significant enlargement of ascending aorta, severe AR with symptoms. Surgery is indicated in all patients with Marfan syndrome and a maximal aortic diameter > 50 mm.
Patient is symptomatic: Acute severe AR needs urgent surgery but any concern about infection may delay surgery e.g. infected aortic valve or aortic root abscess. The only operation is really valve replacement which can be bio prosthetic or metal.
Patient is asymptomatic with severe AR and a resting LVEF of < 50%
Patient is asymptomatic, with LV dilation (LV end-systolic dimension >55 mm)
Patient has severe AR and needs CABG or other valve surgery

References

2017 ESC/EACTS Guidelines for the management of valvular heart disease

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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