Aortic Insufficiency (Regurgitation)

Definition:

• inadequate closure of the aortic valve leaflets 
  

Presentation:

• Cardiogenic Shock
• hypotension, diaphoresis
• shortness of breath

Etiology:

• Acute: 
• Infective endocarditis
• Trauma
• Aortic dissection
• Chronic
• Rheumatic fever
• Bicuspid aortic valve
• Marfan’s syndrome
• Ehlers–Danlos syndrome
• Ankylosing spondylitis
• Systemic Lupus Erythematosus (SLE)

Physical Exam:

• Murmurs - may present with three different types of murmurs. AS: Aortic Stenosis-like. AR: Aortic Regurgitation. AFM: Austin-Flint Murmur   

• Right Upper Sternal Border: Aortic Stenosis-like (AS) - damaged valve presents with aortic-stenosis like murmur. Murmur intensity increases with sustained handgrip. Handgrip increases SVR, which causes an increased “backflow” through the incompetent aortic valve.
• Left Sternal Border: Aortic Regurgitation (AR) blowing diastolic decrescendo murmur
• Cardiac apex: Austin–Flint murmur (AFM)—low-pitched mid-diastolic rumble due to competing flow anterograde from left atrium and retrograde from the aorta. Similar to murmur appreciated in mitral stenosis.
• Displaced PMI (down and to left) S3
  
• Widened pulse pressure— markedly ?SBP with ?DBP ??
  
• Corrigan’s pulse: (water-hammer pulse)  rapidly increasing pulse that collapses suddenly as arterial pressure decreases rapidly in late systole and diastole; can be palpated at wrist or femoral arteries
• De Musset’s sign: head bobs with heartbeat
• Müller’s sign: Uvula bobs
• Duroziez’s sign: femoral bruit; pistol-shot sound 

Diagnosis: 

• Chest XR - might show pulmonary edema and widened mediastinum due to dissection. 
• Echocardiography - the gold standard. May show dilated aortic root and reversal of blood flow in aorta; early closure of mitral valve.
  

Management:

• Definitive Treatment
• Aortic valve replacement 
  
• Pharmacologic Temporizing Measures
• Vasodilators —> nitroprusside will help reduce after load 
• Inotropes —> dobutamine