Aortic Regurgitation

• What is aortic regurgitation?

  Incomplete closure of aortic valve leaflets → blood leaks back into LV during diastole

  Can be due to dilatation of the aortic root or abnormalities in the valve leaflets
• What are the investigations for AR?

  ECG -> may shown non-specific ST-T wave changes, L axis deviation or conduction abnormalities

  CXR -> may show cardiomegaly

  Echo with Doppler -> evaluate severity & cause of AR, evaluate severity of regurgitant flow
• What are the DDs of AR?

  Mitral regurgitation

  Mitral stenosis

  Aortic stenosis

  Pulmonary regurgitation
• What are the RFs of AR?

  Bicuspid aortic valve

  Rheumatic fever

  Infective endocarditis

  Marfan’s, Ehler Danlos syndrome

  Connective tissue diseases (RA/SLE)

  Aortitis

  HTN

  Spondyloarthropathies (e.g. ankylosing spondylitis)

  Aortic dissection
• What are the signs & symptoms of AR?

  Early diastolic murmur

  Dyspnoea

  Fatigue

  Weakness

  Palpitations

  Collapsing pulse

  Wide pulse pressure

  Quinke's sign (nailbed pulsation)

  De Musset's sign (head bobbing)
• What is the general management of AR?

  Medical management (of any associated HF)

  Surgical repair

  Replacement of valve

  Transcatheter aortic valve replacement (TAVR)
• What is the management of AR?

  Management of airway

  Positive inotropic agents (dobutamine) & vasodilator (sodium nitroprusside)

  Urgent surgery (definitive management)
• Pathophys of acute AR

  Acute rise in LA pressure → pulmonary oedema & cardiogenic shock → end-diastolic pressure in LV rises sharply → compensation by increasing heart rate and contractility (Starling's law), but this fails to maintain normal stroke volume

  Medical emergency with high mortality
• Pathophys of chronic AR

  LV volume & pressure overload -> increased wall tension -> compensated hypertrophy -> can sustain this for decades -> eventually LV systolic dysfunction supervenes LV end-diastolic pressure rises -> symptomatic CHF