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Q1: Define aortic regurgitation and contrast chronic vs acute disease (2 min)
AR is diastolic incompetence of the aortic-valve complex (leaflets, annulus, sinuses of Valsalva, ascending aorta) allowing backflow from aorta to LV. Chronic AR is compensated for years by eccentric hypertrophy (sarcomeres in series) — wide pulse pressure, water-hammer pulse, florid peripheral signs, long decrescendo murmur, preserved EF. Acute AR (endocarditis, type A dissection, trauma, prosthetic dehiscence) has no time for remodelling — abrupt rise in LVEDP, acute pulmonary oedema, cardiogenic shock; peripheral signs are absent and the murmur is short/soft because aortic and LV diastolic pressures equalise rapidly. Acute AR is a surgical emergency.[1]
Q2: Causes — leaflet vs aortic root (2 min)
Leaflet disease: rheumatic (scarring, usually mixed mitral disease), bicuspid aortic valve (commonest congenital cause; associated coarctation and aortopathy), infective endocarditis, degenerative calcification, myxomatous prolapse, drug-induced (fenfluramine). Root/annular disease (normal leaflets pulled apart): Marfan, Loeys-Dietz, vascular Ehlers-Danlos, bicuspid aortopathy, hypertension, senile ectasia, tertiary syphilis (luetic aortitis — classically spares the sinuses), seronegative arthropathies (ankylosing spondylitis, reactive, psoriatic), rheumatoid, giant-cell arteritis, Takayasu, relapsing polychondritis. The distinction matters surgically: leaflet disease needs valve replacement; root disease with normal leaflets may allow a valve-sparing David procedure.[2]
Q3: Bedside assessment and named signs (3 min)
The murmur: early-diastolic, high-pitched, blowing, decrescendo, best at the left 3rd intercostal space (Erb point), diaphragm, patient sitting forward in expiration. It is the finding that carries the diagnostic weight — present, it argues strongly for AR (positive likelihood ratio 8.8 to 32 for mild or greater AR); absent, it argues strongly against (negative likelihood ratio 0.1 to 0.3). Two companion findings: Austin Flint (apical mid-diastolic rumble, no opening snap; classically called a functional MS, but mechanistically the regurgitant jet striking the LV endocardium) and soft/absent A2. Pulse and peripheral signs of wide pulse pressure: Corrigan (water-hammer), de Musset (head bob), Quincke (nail beds), Traube (pistol-shot), Duroziez (femoral to-and-fro with compression), Hill (popliteal SBP exceeds brachial by over 20 mmHg), Mueller (uvula), Becker (retinal) — only Flint, Corrigan, Duroziez and Hill have real supporting literature, and apart from Hill their specificity is poor. Apex: displaced, diffuse, hyperdynamic/thrusting (volume overload). Blood pressure: wide pulse pressure. Differential: Graham Steell (pulmonary regurgitation — loud P2, RV heave, pulmonary hypertension), mitral stenosis (opening snap, presystolic accentuation), PDA (continuous machinery).[3][4][5]
Q4: Investigations (2 min)
ECG: LVH (Sokolow-Lyon), LV strain, LA enlargement. CXR: cardiomegaly with the apex displaced down and out, dilated ascending aorta. Transthoracic echo is first-line and central — mechanism, severity (jet/LVOT ratio 65 percent or above, vena contracta over 6 mm, regurgitant volume 60 mL/beat or above, fraction 50 percent or above, EROA 0.30 cm2 or above, PHT under 200 ms, holodiastolic flow reversal in the proximal abdominal aorta), LV dimensions (LVESD, LVEDD) and EF. TOE: vegetations, root anatomy, dissection flap. Cardiac MRI: gold standard for LV volumes and regurgitant fraction. Coronary angiography pre-operatively in patients at risk of coronary disease (not diagnostic in the echo era).[1][2]
Q5: Management and surgical thresholds (3 min)
Acute severe AR = surgical emergency; never IABP; treat the cause (endocarditis, type A dissection) and bridge with oxygen, diuretics, NIV and IV vasodilator (sodium nitroprusside) — in dissection, rate control with IV esmolol first, vasodilator second. Chronic AR: surgery (AVR) when symptomatic; OR asymptomatic with EF 55 percent or below (ACC/AHA 2020) or 50 percent or below (ESC/EACTS 2021); OR asymptomatic with LVESD over 50 mm or indexed over 25 mm/m2 (Class I for ESC, Class IIa for ACC/AHA with a normal EF); OR severe AR at the time of other cardiac or aortic surgery; consider when serial studies show the EF falling into the 55 to 60 percent band or LVEDD over 65 mm. Operative options: surgical AVR (mechanical under ~60y / bioprosthetic over ~65y), valve-sparing David (root aneurysm, normal leaflets), Ross (children/young), TAVI not recommended for pure native AR in a surgical candidate. Medical: guideline-directed heart-failure therapy (ACEi/ARB/sacubitril-valsartan) when surgery is prohibitive; vasodilators do NOT delay surgery (nifedipine and enalapril failed to do so in a randomised trial); avoid beta-blocker monotherapy (bradycardia worsens regurgitation). Surveillance: mild AR every 3 to 5 years; moderate every 1 to 2 years; severe asymptomatic at least yearly, 3- to 6-monthly when numbers are moving. Endocarditis prophylaxis only for highest-risk cardiac conditions before dental procedures (and not routinely at all under NICE).[1][2][6]
References6ShowHide
- [1]Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines J Am Coll Cardiol, 2021.PMID 33342587
- [2]Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease Eur Heart J, 2022.PMID 34453165
- [3]Landzberg JS, Pflugfelder PW, Cassidy MM, et al. Etiology of the Austin Flint murmur J Am Coll Cardiol, 1992.PMID 1634679
- [4]Choudhry NK, Etchells EE The rational clinical examination. Does this patient have aortic regurgitation? JAMA, 1999.PMID 10376577
- [5]Babu AN, Kymes SM, Carpenter Fryer SM Eponyms and the diagnosis of aortic regurgitation: what says the evidence? Ann Intern Med, 2003.PMID 12729428
- [6]Evangelista A, Tornos P, Sambola A, et al. Long-term vasodilator therapy in patients with severe aortic regurgitation N Engl J Med, 2005.PMID 16192479