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Aortic valve regurgitation

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	- Introduction - Causes - Diagnosis - Treatment
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Clinical picture

Most often aortic valve regurgitation develops gradually, and the heart compensates for the problem. Aortic regurgitation usually progresses slowly over years. Mild aortic regurgitation produces no symptoms other than a characteristic heart murmur on auscultation. Many people do well despite moderate to severe regurgitation of the aortic valve. However, as aortic valve regurgitation progresses, signs and symptoms usually appear and may include:

Symptoms

• Fatigue and weakness, especially when the activity level is increased

• Shortness of breath, especially with exertion or when lying flat

• Bloody cough

• Angina pectoris – about 5% chest pain, discomfort or tightness, often increasing during exercise

• Fainting

• Rapid or irregular pulse

• Palpitations

• Oedema that shows as swollen ankles and feet

Signs

The physical examination of an individual with aortic insufficiency involves auscultation of the heart to listen for the murmur of aortic insufficiency and related heart sounds. The murmur of chronic aortic insufficiency is a holodiastolic (lasts all of diastole) decrescendo murmur (starts off loud and becomes soft). The murmur of chronic aortic insufficiency has the following characteristics:

• Systolic ejection click
• Ejection murmur
• S3 present
• Holodiastolic decrescendo murmur - best heard with patient sitting and leaning forward (If radiation to the right parasternal region, consider ascending aortic aneurysm)
• Austin flint murmur (an apical diastolic rumble due to mitral regurgitation)

Physical signs of aortic insufficiency are related to the wide pulse pressure and the rapid decrease in blood pressure during diastole due to the AI:

• Lighthouse sign (blanching & flushing of forehead)
• de Musset's sign (head nodding in time with the heart beat)
• Ladolfi's sign (alternating constriction & dilatation of pupil)
• Becker's sign (pulsations of retinal vessels)
• Müller's sign (pulsations of uvula)
• Corrigan's pulse (rapid upstroke and collapse of the carotid artery pulse)
• (Watson's) Water-hammer pulse
• Quincke's sign (pulsation of the capillary bed in the nail)
• Mayen's sign (diastolic drop of BP>15 mm Hg with arm raised)
• Rosenbach's sign (pulsatile liver)
• Gerhardt's sign (enlarged spleen)
• Duroziez's sign (systolic and diastolic murmurs heard over the femoral artery when it is gradually compressed)
• Hill's sign (A ≥ 20 mmHg difference in popliteal and brachial systolic cuff pressures, seen in chronic severe AI)
• Traube's sign (a double sound heard over the femoral artery when it is compressed distally)
• Lincoln sign (pulsatile popliteal)
• Sherman sign (dorsalis pedis pulse is quickly located & unexpectedly prominent in age>75 yr)

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Diagnosis

The initial diagnosis may be based on the clinical history, auscultation of the heart, abnormalities in the pulse, and the results of a chest x-ray. Other heart problems can cause signs and symptoms similar to those of aortic valve regurgitation, and it's possible to have more than one disorder at the same time. Common tests used for diagnosis of aortic valve regurgitation include:

• Doppler echocardiogram may be used to measure the volume of blood flowing backward through an aortic valve. This volume is expressed in cubic centimeters per beat.
• Chest X-ray. X-ray of the chest shows an enlargement of the left ventricle.
• Electrocardiogram (ECG) may show signs of an enlarged left ventricle.
• Transesophageal echocardiogram allows more closer look at the aortic valve and a clear picture of the amount of blood flowing through it.
• Exercise tests: Different types of exercise tests help measure tolerance for activity and heart's response to exertion (exercise).
• Cardiac catheterization can specifically show the blood leaking back from the aorta into the left ventricle. Some catheters used in cardiac catheterization have sensor devices (sensors) at the tips that can measure pressure within heart chambers, such as the left ventricle. Pressure may be increased in the left ventricle with aortic valve regurgitation.
• Coronary angiography is performed before surgery because about 20% of people with aortic regurgitation also have coronary artery disease.

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