Aetiology (Causes)
Congenital-
Bicuspid valve or disproportionate cusps
Acquired
Rheumatic disease
Infective endocarditis
Failure of prosthetic heart valve
Aortic dilatation (Marfan's syndrome, aneurysm, dissection, syphilis, ankylosing spondylitis)
Pathophysiology
Symptoms
Mild to moderate AR
Often asymptomatic
Awareness of heart beat, 'palpitations'
Severe AR
Breathlessness
Angina
Signs
Pulses-
Large volume or ‘collapsing pulse’
Low diastolic and increased pulse preassure
Bounding peripheral pulses- A rapidly rising "water-hammer" pulse, which collapses suddenly as arterial pressure falls rapidly during late systole and diastole (Corrigan's pulse)
Capillary pulsations, an alternate flushing and paling of the skin at the root of the nail while pressure is applied to the tip of the nail (Quincke's pulse/sign)
Femoral bruit (‘pistol shot’)- Duroziez’s sign/ Traube’s sign
Head nodding with pulse- de Musset’s sign
Murmurs-
Early diastolic murmur
Systolic murmur (increased stroke volume)
Austin Flint murmur (soft mid-diastolic)
Other signs
Displaced, heaving apex beat (volume overload)
Pre-systolic impulse
Fourth heart sound
Pulmonary venous congestion (crepitations)
Investigatons
ECG –
Initially normal, later LV hypertrophy and T-wave inversion
Chest X-ray –
Cardiac dilatation, maybe aortic dilatation
Features of left heart failure
Echo Dilated left ventricle
Hyperdynamic left ventricle
Fluttering anterior mitral leaflet
Doppler detects reflux
Cardiac catheterisation (may not be required)
Dilated LV
Aortic regurgitation
Dilated aortic root
Treatment
Treat the cause- underlying conditions like endocarditis or syphilis.
Nefidipine or ACE inhibitors to lower the systolic blood preassure.
If end systolic dimension of left ventrical is =>55mm then- Aortic valve replacement is undertaken.
Aortic root replacement – in aortic root dilatation (eg. Marfan syndrome)
Essentials of Diagnosis
Usually asymptomatic until middle age; presents with left-sided failure or chest pain.
Wide pulse pressure.
Hyperactive, enlarged LV.
Diastolic murmur along left sternal border.
ECG shows LVH; radiograph shows LV dilation.
Echocardiography/Doppler is diagnostic.
Afterload reduction is beneficial if the LV is dilated (LV end-diastolic dimension > 5.0 cm).
Surgery indicated for symptoms, EF < 55%, or LV end-systolic dimension > 5.0 cm.
