Aortic regurgitation (AR) Is incompetency of the aortic valve causing flow from the aorta into the left

ventricle during diastole. Causes: Idiopathic valvular degeneration Rheumatic fever Endocarditis Myxomatous degeneration Congenital bicuspid aortic valve Aortic root dilatation or dissection Connective tissue Rheumatologic disorders Symptoms: Exertional dyspnea Orthopnea Paroxysmal nocturnal dyspnea Palpitations Chest pain Signs : widened pulse pressure a Early diastolic murmur Diagnosis is by physical examination and echocardiography. Surgical treatment is aortic valve replacement. Etiology may be acute or chronic. The primary causes of acute AR are: 1. Infective endocarditis 2. Dissection of the ascending aorta Mild chronic AR in adults is most often caused by: Bicuspid or fenestrated aortic valve (2% of men and 1% of women), especially when severe diastolic hypertension (pressure 110 mm Hg) is present Moderate to severe chronic AR in adults is most often caused by: idiopathic degeneration of the aortic valves or root rheumatic fever infective endocarditis myxomatous degeneration trauma In children, the most common cause is a ventricular septal defect with aortic valve prolapse. Rarely, AR is caused by seronegative spondyloarthropathies (ankylosing spondylitis, reactive arthritis, psoriatic arthritis) RA SLE arthritis associated with ulcerative colitis, luetic (syphilitic) aortitis osteogenesis imperfect thoracic aortic aneurysm aortic dissection

supravalvular aortic stenosis Takayasu's arteritis rupture of a sinus of Valsalva acromegaly Temporal (giant cell) arteritis. AR due to myxomatous degeneration may develop in patients with Marfan syndrome or Ehlers-Danlos syndrome. Pathophysiology In chronic AR LV receives aortic blood regurgitated in diastole in addition to blood from the pulmonary veins and left atrium I Left ventricular (LV) volume and LV stroke volume gradually increase I LV hypertrophy compensates for the increase in LV volume over years, but decompensation eventually develops. I These changes may ultimately cause arrhythmias, LV impairment, and heart failure (HF). Symptoms and Signs Acute AR causes symptoms of: HF and cardiogenic shock Chronic AR is typically asymptomatic for years; progressive exertional dyspnea orthopnea paroxysmal nocturnal dyspnea palpitations. Symptoms of HF correlate poorly with objective measures of LV function. Chest pain (angina pectoris) Affects only about 5% of patients who do not have coexisting coronary artery disease (CAD) And, when it occurs, is especially common at night. Patients may present with endocarditis (eg, fever, anemia, weight loss, embolic phenomena) because the abnormal aortic valve is predisposed to bacterial seeding.

Signs vary by severity. As chronic disease progresses: systolic BP increases while diastolic BP decreases Widened pulse pressure the LV impulse may become enlarged, sustained, increased in amplitude, and displaced downward and laterally Systolic depression of the entire left parasternal area, giving a rocking motion to the left chest

systolic apical or carotid thrill may become palpable in later stages of AR It is caused by large forward stroke volumes and low aortic diastolic pressure Auscultatory findings 1. 2. 3. Normal 1st heart sound (S1) Nonsplit, loud, sharp or slapping 2nd heart sound (S2) caused by increased elastic aortic recoil. Unimpressive murmur o The murmur is blowing, high-pitched, diastolic, and decrescendo, beginning soon after the aortic component of S2 (A2); o it is loudest at the 3rd or 4th left parasternal intercostal space. o heard best with the diaphragm of the stethoscope when the patient is leaning forward, with breath held at end-expiration. o It increases in volume in response to maneuvers that increase afterload (eg, squatting, isometric handgrip). o If AR is slight, the murmur may occur only in early diastole. o If LV diastolic pressure is very high, the murmur is short because aortic and LV diastolic pressures equalize earlier in diastole.

popliteal systolic pressure 60 mm Hg higher than brachial pressure (Hill's sign) a fall in diastolic BP of > 15 mm Hg with arm elevation (Mayne's sign). Auscultatory signs include sharp sound heard over the femoral pulse (pistol-shot sound, or Traube's sign) a femoral systolic bruit distal a diastolic bruit proximal to arterial compression (Duroziez's murmur) Diagnosis 1. Echocardiography a. Doppler echocardiography Test of choice to detect and quantify the magnitude of regurgitant blood flow. b. Two-dimensional echocardiography Can quantify aortic root size and anatomy and LV function. 2 An end-systolic LV volume > 60 mL/m , endsystolic LV diameter > 50 mm, and LV ejection fraction (LVEF) < 50% suggest decompensation Echocardiography can also assess severity of pulmonary hypertension secondary to LV failure, detect vegetations or pericardial effusions (eg, in aortic dissection), and provide information about prognosis. Radionuclide imaging used to determine LVEF if echocardiographic results are borderline abnormal or if echocardiography is technically difficult. 3. ECG a. repolarization abnormalities with or without QRS voltage criteria of LV hypertrophy, b. Left atrial enlargement c. T-wave inversion with ST-segment depression in precordial leads Chest x-ray a. cardiomegaly b. Prominent aortic root in patients with chronic progressive AR. 2.

Abnormal sounds forward ejection and backward regurgitant flow (to-and-fro) murmur an ejection click soon after the S1 an aortic ejection flow murmur A diastolic murmur heard near the axilla or mid left thorax (Cole-Cecil murmur) Is caused by fusion of the aortic murmur with the 3rd heart sound (S3), which is due to simultaneous filling of LV from the left atrium and AR. A mid-to-late diastolic rumble heard at the apex (Austin Flint murmur) may result from rapid regurgitant flow into the LV, causing mitral valve leaflet vibration at the peak of atrial flow; this murmur mimics the diastolic murmur of mitral stenosis. Visible signs include head bobbing (Musset's sign) Pulsation of the fingernail capillaries (Quincke's sign, best seen with slight pressure) or uvula (Mller's sign) Palpable signs include large-volume pulse with rapid rise and fall (slapping, water-hammer, or collapsing pulse) pulsation of the carotid arteries (Corrigan's sign) retinal arteries (Becker's sign) liver (Rosenbach's sign), or spleen (Gerhard's sign) BP findings may include

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If AR is severe Signs of pulmonary edema and HF may also be present. Exercise testing Help assess functional capacity and symptoms in patients with documented AR and equivocal symptoms. Coronary angiography Should be done before surgery, even if no angina is present, because about 20% of patients with severe AR have significant CAD, which may need concomitant coronary artery bypass graft surgery. Treatment Aortic valve replacement Sometimes vasodilators, diuretics, and nitrates 6. 5.

Treatment of acute AR is aortic valve replacement. Treatment of chronic AR varies by symptoms and degree of LV dysfunction.

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Patients with symptoms precipitated by normal daily activity or during exercise testing, a. Require aortic valve replacement; b. Patients who prefer to avoid surgery may be treated with vasodilators (eg, long-acting nifedipine30 to 90 mg po once/day or ACE inhibitors). Diuretics or nitrates to reduce preload may be beneficial for severe AR. Asymptomatic patients with LVEF < 55%, an end-systolic diameter 55 mm (55 rule), or an end-diastolic diameter > 75 mm Also require surgery; Oral drugs are a 2nd-best option for this group. Additional surgical criteria have been proposed, including o fractional shortening < 25 to 29% o end-diastolic radius to myocardial wall thickness ratio > 4.0 2 o cardiac index < 2.2 to 2.5 L/min/m Patients who do not meet these criteria should be reevaluated by physical examination, echocardiography, and possibly rest-exercise radionuclide cineangiography to measure LV contractility every 6 to 12 mo. Antibiotic prophylaxis against endocarditis is no longer recommended except for patients who have had valve replacement.

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Table 4 Recommended Endocarditis Prophylaxis During Oral-Dental or Respiratory Tract Procedures* Route Drug and Dosage in Adults (and Children) Drug and Dosage in Adults (and Children) Allergic to Penicillin Clindamycin-600 mg (20 mg/kg) po or Cephalexin/ cefadroxil 2 g (50 mg/kg) po or Azithromycin or clarithromycin 500 mg (15 mg/kg) po Parenteral (given 30 min before procedure) Ampicillin 2 g (50 mg/kg) IM or IV Clindamycin 600 mg (20 mg/kg) IV or Cefazolin 1 g (25 mg/kg) IM or IV *For patients without active infection. Adapted from Wilson W, Taubert KS, Gewitz M, et al: Prevention of infective endocarditis. Circulation116(15):17361754, 2007.

Oral (given 1 h before Amoxicillin procedure) 2 g (50 mg/kg) po