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ESSENTIALS OF DIAGNOSIS
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Usually asymptomatic until middle age; presents with left-sided failure or chest pain Wide pulse pressure Echocardiography/Doppler is diagnostic Afterload reduction is beneficial if the LV is dilated (LV end-diastolic dimension > 50 cm) Surgery indicated for symptoms, EF < 55%, or LV end-systolic dimension > 50 cm
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Rheumatic aortic regurgitation has become much less common than in the preantibiotic era, and nonrheumatic causes now predominate These include congenitally bicuspid valves, infective endocarditis, and hypertension Many patients have aortic regurgitation secondary to aortic root diseases such as cystic medial necrosis, Marfan syndrome, or aortic dissection Rarely, inflammatory dis-
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primarily as pulmonary edema, may develop rapidly; surgery is urgently required in such cases Patients with acute aortic regurgitation do not have the dilated LV of chronic aortic regurgitation and the extra volume is handled poorly For the same reason, the diastolic murmur is shorter and may be minimal in intensity, and the pulse pressure may not be widened, making clinical diagnosis difficult The mitral valve may close prematurely before systole has been initiated (pre-closure) due to the rapid rise in the LV diastolic pressure and the first heart sound is thus diminished or inaudible
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eases, such as ankylosing spondylitis or Reiter s syndrome, may be causative Chronic aortic regurgitation presents both an increased preload and an increased afterload to the LV The response to these effects is to hypertrophy by laying sarcomeres end to end, increasing the LV chamber size greater than the wall thickness (eccentric hypertrophy) The amount of LVH in chronic aortic regurgitation is substantial and greater than that seen in aortic stenosis or mitral regurgitation
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Clinical Findings
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The clinical presentation is determined by the rapidity with which regurgitation develops In chronic regurgitation, the only sign for many years may be a soft aortic diastolic murmur As the severity of the aortic regurgitation increases, diastolic BP falls, and the LV progressively enlarges Most patients remain asymptomatic even at this point LV failure is a late event and may be sudden in onset Exertional dyspnea and fatigue are the most frequent symptoms, but paroxysmal nocturnal dyspnea and pulmonary edema may also occur Angina pectoris or atypical chest pain may occasionally be present Associated CAD and presyncope or syncope are less common than in aortic stenosis Hemodynamically, because of compensatory LV dilation, patients eject a large stroke volume, which is adequate to maintain forward cardiac output until late in the course of the disease LV diastolic pressure may rise when heart failure occurs Abnormal LV systolic function, as manifested by reduced EF (< 55%) and increasing end-systolic LV volume (> 5 cm), is a sign that surgical intervention is warranted The major physical findings in chronic aortic regurgitation relate to the high stroke volume being ejected into the systemic vascular system with rapid runoff as the regurgitation takes place (see Table 10 1) This results in a wide arterial pulse pressure The pulse has a rapid rise and fall (waterhammer pulse or Corrigan s pulse), with an elevated systolic and low diastolic pressure The large stroke volume is also responsible for characteristic findings such as Quincke s pulses (subungual capillary pulsations), Duroziez s sign (to and fro murmur over a partially compressed peripheral artery, commonly the femoral), and Musset s sign (head bob with each pulse) In younger patients, the increased stroke volume may summate with the reflected wave from the periphery and create an even higher systolic pressure in the extremity compared with the central aorta Since the peripheral bed is much larger in the leg than the arm, the BP in the leg may be over 40 mm Hg higher than in the arm (Hill s sign) The apical impulse is prominent, laterally displaced, usually hyperdynamic, and may be sustained A systolic murmur is usually present and may be quite soft and localized; the aortic diastolic murmur is usually high-pitched and decrescendo A mid or late diastolic low-pitched mitral murmur (Austin Flint murmur) may be heard in advanced aortic regurgitation, owing to obstruction of mitral flow produced by partial closure of the mitral valve by the regurgitant jet and the rapidly rising LV diastolic pressure In acute aortic regurgitation (as from aortic dissection or infective endocarditis), LV failure, which is manifested
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