Aortic Regurgitation

Physical Examination

General examination:

• Dyspnea or fatigue in advanced cases

• Peripheral signs of AR:

  • Corrigan's pulse (rapidly rising, collapsing pulse)

  • Corrigan’s sign (hyperactive carotid pulsation)

  • Dancing brachial artery

  • Quincke's sign (capillary pulsation in the nail bed)

  • De Musset's sign (rhythmic head nodding with each heartbeat)

  • Traube's sign (pistol-shot sound over the femoral artery)

  • Duroziez's sign (systolic and diastolic murmurs over the femoral artery)

  • Müller's sign (pulsation of the uvula)

Precordial inspection:

• Visible apical impulse in severe cases

Palpation:

• Displaced apical impulse, if left ventricular enlargement is present

• Hyperdynamic or "thrilling" apical impulse

• Systolic thrill at the base of the heart (less common)

Auscultation:

• Diastolic decrescendo murmur, best heard at the left sternal border in the 3rd or 4th intercostal space with the patient sitting up and leaning forward, holding their breath in expiration

• S3 gallop due to increased left ventricular filling volume (in severe AR)

• Austin Flint murmur (mid-diastolic rumble at the apex due to turbulent flow between the regurgitant jet and the mitral valve inflow)

Additional examination:

• Blood pressure measurement: wide pulse pressure (high systolic and low diastolic pressures)

• Assess for signs of heart failure (jugular venous distension, pulmonary crackles, peripheral oedema) if AR is severe

Detect Underlying Cause

• Marfan syndrome:

  • Tall stature with disproportionately long limbs

  • Arachnodactyly (long, slender fingers and toes)

  • Pectus excavatum (sunken chest) or pectus carinatum (protruding chest)

  • High-arched palate or crowded teeth

  • Hypermobile joints

• Ehlers-Danlos syndrome:

  • Hypermobile joints

  • Skin that is easily bruised, hyperextensible, or has atrophic scarring

  • High-arched palate or crowded teeth

• Ankylosing spondylitis:

  • Reduced spinal mobility and chest expansion

  • Kyphosis or exaggerated thoracic curvature

  • Sacroiliac joint tenderness

  • Uveitis or iritis (red, painful eye)

• Infective endocarditis:

  • Fever

  • Osler's nodes (tender nodules on fingers or toes)

  • Janeway lesions (non-tender, erythematous or hemorrhagic macules on palms or soles)

  • Splinter haemorrhages (linear, reddish-brown streaks under the nails)

  • Roth spots (retinal haemorrhages with pale centres)

• Syphilitic aortitis:

  • Signs of tertiary syphilis, such as gummas (granulomatous lesions) on the skin or internal organs

  • Neurological signs (tabes dorsalis, general paresis) or ophthalmic signs (Argyll Robertson pupils, optic atrophy)

• Rheumatic heart disease:

  • History of rheumatic fever or recurrent streptococcal infections

  • Mitral valve involvement (mitral stenosis or regurgitation)

  • Signs of chronic rheumatic carditis (cardiomegaly, heart failure)

Investigations

Laboratory:

• Complete blood count (e.g., anemia in chronic heart failure)

• Basic metabolic panel (e.g., renal function, electrolytes)

• Liver function tests (e.g., congestive hepatopathy in heart failure)

• Natriuretic peptides (BNP or NT-proBNP, elevated in heart failure)

• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP, elevated in infective endocarditis or rheumatic fever)

• Blood cultures (to identify causative organisms in infective endocarditis)

• Serology for syphilis (VDRL or RPR, followed by confirmatory tests if positive)

Imaging:

• Chest X-ray (to assess cardiomegaly, pulmonary congestion, or a widened mediastinum in aortic root dilation)

• Echocardiography (transthoracic or transesophageal, to assess aortic valve morphology, the severity of regurgitation, left ventricular size and function, and other associated valvular abnormalities)

• Cardiac magnetic resonance imaging (MRI, for a detailed assessment of the aortic valve, aortic root, and left ventricular structure and function)

Invasive tests:

• Cardiac catheterisation and angiography (to assess the severity of aortic regurgitation, evaluate coronary arteries for concomitant coronary artery disease, and measure left ventricular function)

Other tests:

• Electrocardiogram (ECG, to evaluate for left ventricular hypertrophy, arrhythmias, or ischemia)

• Exercise testing or stress echocardiography (to evaluate exercise capacity, the hemodynamic response to exercise, and inducible ischemia)

• Holter or event monitor (to detect arrhythmias or conduction abnormalities)

Management

General management:

• Monitor for symptom progression and changes in clinical examination

• Regular follow-up with echocardiography to assess valve and ventricular function

• Treat underlying cause, if identified (e.g., antibiotics for infective endocarditis)

• Lifestyle modifications, including salt and fluid restriction, regular exercise, and weight management

Medical management:

• Heart failure medications, if indicated:

  • Angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs): to reduce afterload and improve ventricular function

  • Beta-blockers: to improve ventricular function and manage arrhythmias

  • Diuretics: to manage congestion and fluid overload

  • Aldosterone antagonists (Spironolactone): for additional diuresis and heart failure management

• Rate control for atrial fibrillation, if present (e.g., beta-blockers, non-dihydropyridine calcium channel blockers)

• Anticoagulation for atrial fibrillation, if indicated (e.g., direct oral anticoagulants, warfarin)

Surgical management:

• Aortic valve repair or replacement:

  • Indications: symptomatic severe AR, asymptomatic severe AR with left ventricular dysfunction or dilation, moderate AR undergoing other cardiac surgery, endocarditis not responding to medical therapy

  • Valve replacement options: mechanical valve (requires lifelong anticoagulation) or bioprosthetic valve (limited durability)

  • Transcatheter aortic valve implementation (TAVI) may be considered in select high-risk patients

• Aortic root or ascending aorta surgery, if aneurysm or dissection is present

Causes of Aortic Regurgitation

• Acute Causes:

  • Infective endocarditis

  • Aortic dissection

  • Trauma

• Chronic Causes:

  • Aortic root disease:

    • Aortic root dilation (e.g., Marfan syndrome, Ehlers-Danlos syndrome)

    • Aortic aneurysm

    • Syphilitic aortitis

  • Aortic valve disease:

    • Rheumatic heart disease

  • Connective tissue disorders:

    • Systemic lupus erythematosus (Libman-Sacks endocarditis)

    • Rheumatoid arthritis

    • Ankylosing spondylitis

Collapsing Pulse

A collapsing pulse, also known as a water hammer or Corrigan's pulse, is a rapid, forceful pulse that quickly collapses under the examining fingers. It is associated with a rapid upstroke and downstroke and is indicative of a large stroke volume with rapid ejection and rapid decline in arterial pressure.

Causes of Collapsing Pulse:

• Aortic regurgitation

• Arteriovenous fistula (AVF)

• Hyperdynamic circulation

  • Anaemia

  • Thyrotoxicosis

  • Fever

  • Pregnancy

  • Beri Beri

Severity of Aortic Regurgitation

• Wide pulse pressure

• Long duration of decrescendo diastolic murmur

• Third heart sound

• Austin flint murmur

• Signs of pulmonary hypertension

• Signs of left ventricular failure