EtiologyEtiology **Any conditions resulting in Any conditions resulting in

incompetent aortic leafletsincompetent aortic leaflets

__CongenitalCongenital Bicuspid AVBicuspid AV

_ _ AortopathyAortopathyCystic medial necrosisCystic medial necrosis

Collagen disorders (.Marfan SynCollagen disorders (.Marfan Syn].]. Ehler-DanlosEhler-Danlos

Osteogenesis imperfectaOsteogenesis imperfecta Pseudoxanthoma elasticumPseudoxanthoma elasticum

_ _ AcquiredAcquired

* * Rheumatic heart diseaseRheumatic heart disease

* * Dilated aorta ] hyperte.]Dilated aorta ] hyperte.]

* * DegenerativeDegenerative

* * Connective tissue disorderConnective tissue disorder

_ _ AnkylosingAnkylosing spondylitis, spondylitis, _Rheumatoid arthritis, _Rheumatoid arthritis, _Reiter’s syndrome, _Reiter’s syndrome,

_Giant-cell arteritis_Giant-cell arteritis( (

* * Syphilis (chronic aortitis)Syphilis (chronic aortitis)

* * Acute ARAcute AR::

_ ,_ ,Infective endocarditis, Infective endocarditis, _Trauma_Trauma

_ _ Dissecting aneurysmDissecting aneurysm

LVDOL…. LV dilatation …. Increased SV ….. Wide PP…..LVH …Dilated LA

…. Increased LVEDP……LAP rise..…

Pulmonary congestion …. PH …. RVH

……RVF

Chronic AR Elevated LV end-diastolic pressure and

volume Dilatation and eccentric hypertrophy of

the LV Increased stroke volume

Left ventricular EF normal Gradually LV preload and afterload

both increased Ultimately, adaptive measures fail .

LV function deteriorates End-diastolic volume rises further (the

largest heart) Myocardial ischemia Decline in forward stroke volume and

EF

SymptomsSymptoms

__Dyspnea, orthopnea, PNDDyspnea, orthopnea, PND __Chest painChest pain..

Nocturnal angina >> exertional anginaNocturnal angina >> exertional angina { { diastolic aortic pressure and increased diastolic aortic pressure and increased

LVEDP thus LVEDP thus coronary artery coronary artery diastolic flow diastolic flow}}

* * With extreme reductions in diastolic pressures With extreme reductions in diastolic pressures {e.g. < 40} may see angina {e.g. < 40} may see angina

Mild to moderate AR:

*Often asymptomatic * Palpitation

Severe AR:

__Quincke’s sign: capillary Quincke’s sign: capillary pulsationpulsation

_ _ Corrigan’s sign: _Water Corrigan’s sign: _Water hammer pulsehammer pulse

_ _ Bisferiens pulse (AS/AR > AR)Bisferiens pulse (AS/AR > AR)

_ _ De Musset’s sign: systolic De Musset’s sign: systolic head bobbinghead bobbing

_ _ Mueller’s sign: systolic Mueller’s sign: systolic pulsation of uvulapulsation of uvula

__Durosier’s sign: femoral Durosier’s sign: femoral retrograde bruitsretrograde bruits

_ _ Traube’s sign: pistol shot Traube’s sign: pistol shot femoralsfemorals

_ _ Hill’s sign:BP Lower Hill’s sign:BP Lower extremity >BP Upper extremity >BP Upper extremity byextremity by

<_ <_ 2020 mm Hg - mild ARmm Hg - mild AR

<_ <_ 4040 mm Hg – mod ARmm Hg – mod AR

<_ <_ 6060 mm Hg – severe ARmm Hg – severe AR

Wave Sound

Peripheral Signs

Central Signs of SevereCentral Signs of Severe ApexApex::

__EnlargedEnlarged

_ _ DisplacedDisplaced

_ _ Hyper-Hyper-dynamicLforcible dynamicLforcible nonsustainednonsustained

_ _ Palpable S3Palpable S3

_ _ Austin-Flint murmurAustin-Flint murmur

Aortic diastolic murmurAortic diastolic murmur

_ _ Length correlates Length correlates with severity with severity {chronic AR}{chronic AR}

_ _ In acute AR murmur In acute AR murmur shortens as shortens as Aortic DP=LVEDPAortic DP=LVEDP

_ _ In acute AR - mitral In acute AR - mitral pre-closurepre-closure

AUSCULTATIONAUSCULTATION

Murmur: high-pitched, blowing, decrescendo diastolic murmur, heard best in the third Murmur: high-pitched, blowing, decrescendo diastolic murmur, heard best in the third

intercostal space along the left sternal border (holodiastolic in severe AR)intercostal space along the left sternal border (holodiastolic in severe AR)

When the murmur is soft, it can be heard best with the diapgm hraof the stethoscope and When the murmur is soft, it can be heard best with the diapgm hraof the stethoscope and

with the patient sitting up, leaning forward, and with the breath held in forced expirationwith the patient sitting up, leaning forward, and with the breath held in forced expiration . .

10

Widened pulse pressureWidened pulse pressure systolic – diastolic = pulse systolic – diastolic = pulse

pressurepressure __

Physical examination

A mid-systolic ejection murmur frequently audible in isolated ARA mid-systolic ejection murmur frequently audible in isolated AR

Flint murmurFlint murmur, a soft, low-pitched, rumbling mid-diastolic murmur probably , a soft, low-pitched, rumbling mid-diastolic murmur probably

produced by the diastolic displacement of the anterior leaflet of the mitral produced by the diastolic displacement of the anterior leaflet of the mitral

valve by the AR stream not due to hemodynamically significant mitral valve by the AR stream not due to hemodynamically significant mitral

obstructionobstruction

11

Common Murmurs and TimingCommon Murmurs and Timing

_,_,Systolic MurmursSystolic Murmurs

_ _Aortic stenosisAortic stenosis _ _Mitral insufficiencyMitral insufficiency

__Mitral valve prolapseMitral valve prolapse__Tricuspid insufficiencyTricuspid insufficiency

Diastolic MurmursDiastolic Murmurs

__Aortic insufficiencyAortic insufficiency__Mitral stenosisMitral stenosis

S1 S2 S1

Investigations:

*ECG :- LVH + T inversion

*Chest XR :- _ Cadiac dilatation _ Aortic dilatation

_ Pulmonary congestion

*ECHO :- _Dilated LV _ Hyperdynamic LV

_ Fluttering AML _ Doppler detects reflux

*Cardiac Catheterization-:

_ Dilated LV _ AR

_ Dilated aortic root

Chest XR PA view

ECG

Assessing severity of ARAssessing severity of AR

* * Assess severity by impact on peripheral signs and LVAssess severity by impact on peripheral signs and LV peripheral signs = peripheral signs = severity severity

LV = LV = severity severity

S3S3

Austin –Flint murmerAustin –Flint murmer

LVHLVH

radiological cardiomegalyradiological cardiomegaly

Natural historyNatural history: :

**Asymptomatic %/YAsymptomatic %/Y Normal LV function }--good prognosis{Normal LV function }--good prognosis{

_ _ Progression to symptoms or LV dysfunction < 6Progression to symptoms or LV dysfunction < 6_ _ Progression to asymptomatic LV dysfunction < 3.5Progression to asymptomatic LV dysfunction < 3.5

_ _ 55--year survival 75%year survival 75%<0.2<0.2 _Sudden death _Sudden death

Abnormal LV functionAbnormal LV function_ _ Progression to cardiac symptoms 25Progression to cardiac symptoms 25

* * Symptomatic }poor prognosisSymptomatic }poor prognosis_ _ Mortality >10%Mortality >10%

Bonow RO, et al, JACC. 1998;32:1486.

TX: Medical Surgery BEFORE LV dysfunction

Management :

*Medical :

_ Vasodilator { ACEIs } _ Diuretics for pulmonary congestion

_ Prophylaxis against IE _Treatment of underline cause e.g.

IE , Syphilis

*Surgical :

_ AV replacement Mechanical or Bioprosthesis

_ Aortic root replacement for dilated A root , {e.g. Syphilis,

Marfan`s syndrome , Dissecting aneurysm{

* EHO indications for AVR : _LVEDD >55 _EF > 55% _FS > 27%

Criteria for Aortic Valve Replacement in Criteria for Aortic Valve Replacement in Chronic Aortic RegurgitationChronic Aortic Regurgitation

SymptomsSymptomsCongestive heart failureCongestive heart failure..Declining exercise tolerance on exercise testingDeclining exercise tolerance on exercise testing..

AnginaAngina

Anatomy, regardless of symptomsAnatomy, regardless of symptoms::Left ventricular dysfunction: EF <50%Left ventricular dysfunction: EF <50%

Progressive left ventricular dilation or decline in Progressive left ventricular dilation or decline in EF on EF on serial studiesserial studiesSevere dilation Severe dilation (echo)(echo)::

- - Left ventricular diastolic dimension >75 mmLeft ventricular diastolic dimension >75 mm - - Left ventricular systolic dimension >55 mmLeft ventricular systolic dimension >55 mm

- - Aortic root dimension >50 mmAortic root dimension >50 mm