Valvular

Aortic Regurgitation AKA Aortic Insufficiency

PATHO

  • Aortic valve doesn't close all the way ➔ blood leaking back into LV during diastole

  • Acute: Endocarditis, ascending aorta dissection, MI

    • Sudden severe regurgitation ➔ left ventricle can't dilate ➔ rapid ↑ ↑ diastolic LV pressure ➔ backs up pulmonary circulation

  • Chronic: Congenital (bicuspid), rheumatic heart disease; syphilis or Marfan ➔ dilated aorta

    • Compensation maintains output (compensated HF) but eventually ➔ eccentric hypertrophy (because LV dilating) ➔ systolic dysfunction

SSX

  • S3 (from passive filling of dilated ventricle)

  • Diastolic decrescendo (blowing, harsh/high-pitch) that worsens with ↑ afterload (handgrip)

  • Acute ➔ circling the drain

    • Sudden left HF ➔ pulmonary edema ➔ severe dyspnea

  • Chronic ➔ left HF, angina, palpitations

    • Wide pulse pressure (Systolic BP - Diastolic BP = pulse pressure)

      • Regurgitated blood + LA blood ➔ ↑ preload ➔ ↑ systolic BP but crappy valve lets blood back into LV ➔ ↓ diastolic BP

    • de Musset sign: head bobbing to their own heart beat

    • Water Hammer (bounding pulse): rapid upstroke and downstroke in peripheral arteries

    • Quincke sign: capillary pulse is visible

    • Laterally displaced PMI

DX

  • ECHO (Transthoracic) doppler shows regurgitant AR

  • CXR shows prominent/dilated aortic arch

  • Cardiac cath not usually needed for dx

TX

  • ASX or non-surgical: ACEi/ARB

  • Surgery for severe sx or ASX with severe AR (↓ ejection fraction)

  • Want to use meds that ↓ afterload: ACEi/ARB, direct vasodilators