Aortic regurgitation is the diastolic flow of blood from the aorta into the left ventricle.

Regurgitation is due to incompetence of the aortic valve or any disturbance of the valvular apparatus (eg, leaflets, annulus of the aorta) resulting in diastolic flow of blood into the left ventricular chamber. the leakage of blood may prevent your heart from efficiently pumping blood out to the rest of your body. If your heart isn't working efficiently, you may feel fatigued and short of breath. Aortic valve regurgitation can develop suddenly or over decades. It has a variety of causes, such as rheumatic fever. Once aortic valve regurgitation becomes severe, surgery is usually required to repair or replace the aortic valve.

Incompetent closure of the aortic valve can result from intrinsic disease of the cusp, diseases of the aorta, or trauma. Aortic regurgitation may be a chronic disease process or it may occur acutely, presenting as heart failure. The most common cause of chronic aortic regurgitation used to be rheumatic heart disease, but presently it is most commonly bacterial endocarditis. In developed countries, it is caused by dilatation of the ascending aorta (eg, aortic root disease, aortoannular ectasia). Diastolic reflux through the aortic valve can lead to left ventricular volume overload. The severity of the aortic regurgitation is dependent on the diastolic valve area, the diastolic pressure gradient between the aorta and left ventricle, and the duration of diastole. An increase in systolic stroke volume and low diastolic aortic pressure produces an increased pulse pressure. Signs And Symptoms Of Aortic Valve Regurgitation Most often aortic valve regurgitation develops gradually, and your heart compensates for the problem. You may have no signs or symptoms for many years, and you may even be unaware that you have this condition. However, as aortic valve regurgitation progresses, signs and symptoms usually appear and may include:

Fatigue and weakness, especially when you increase your activity level Shortness of breath, especially with exertion or when you lie flat Chest pain, discomfort or tightness, often increasing during exercise Fainting Rapid or irregular pulse Heart palpitations sensations of a rapid, fluttering heartbeat Swollen ankles and feet

Physical

The hallmark of aortic regurgitation/insufficiency is a high-pitched decrescendo diastolic murmur at the left sternal border after the second heart sound. Acute aortic regurgitation o Patients who have CHF or shock associated with severe aortic regurgitation often appear gravely ill. o Tachycardia o Peripheral vasoconstriction o Cyanosis o Pulmonary edema o Arterial pulsus alternans; normal left ventricular impulse o Early diastolic murmur (lower pitched and shorter than in chronic aortic regurgitation) may be present. An Austin-Flint murmur, which is caused by the regurgitant flow causing vibration of the mitral apparatus, is lower pitched and short in duration. The decrescendo diastolic murmur is heard best with the patient leaning forward in full expiration in a quiet room. It is the cardiac murmur most commonly missed. o A murmur at the right sternal border is associated more often with dissection than any other cause of aortic regurgitation.

Chronic aortic regurgitation o All auscultatory phenomena indicate vasodilatation of peripheral circulation. o Hyperdynamic apical impulse displaced laterally and inferiorly may be associated with an ejection click. o Decrescendo diastolic murmur is heard best while the patient is leaning forward on deep expiration. o Apical middiastolic rumble o Austin-Flint murmur o Pulsus bisferiens; increased pulse pressure; visible, forceful, and bounding peripheral pulses (water hammer) o Corrigan pulse - Quickly collapsing pulses o Musset sign - Bobbing of the head o Quincke sign - Capillary pulsations of the nail bed o Muller sign - Pulsations of the uvula o Hill sign - Systolic pressure in lower extremity greater than systolic pressure in upper extremity by at least 100 mm Hg

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Traube sign - Loud systolic sound over femoral arteries Duroziez sign - Systolic-diastolic murmur produced by compression of femoral artery with a stethoscope

Causes Of Aortic Valve Regurgitation Aortic valve regurgitation disrupts the way blood normally flows through your heart and its valves. Any condition that damages the aortic valve can cause regurgitation. Causes of aortic valve regurgitation may be:

A congenital heart defect. You may have been born with an aortic valve that has one leaflet (unicuspid valve) or two leaflets (bicuspid valve) rather than the normal three leaflets. Deterioration of the valve with age. The aortic valve opens and shuts tens of thousands of times a day, every day of your life. Aortic valve regurgitation may result from age-related wear and tear on the valve. Endocarditis. The aortic valve may be damaged by endocarditis an infection inside your heart that involves heart valves. Rheumatic fever. Rheumatic fever a complication of strep throat and once a common childhood illness in the United States can damage the aortic valve, leading to aortic valve regurgitation later in life. Other causes. Other, rarer conditions that can damage the aortic valve and lead to regurgitation include Marfan syndrome (a disease of connective tissue), ankylosing spondylitis (a spine disorder) and syphilis (a sexually transmitted disease). Damage to the aorta near the site of the aortic valve, such as damage from trauma to your chest or from a tear in the aorta, also can cause backward flow of blood through the valve.

Imaging Studies

Chest radiography o Acute aortic regurgitation Minimal cardiac enlargement Normal aortic root/arch Pulmonary venous pattern increased o Chronic aortic regurgitation Marked cardiac enlargement Prominent aortic root/arch Normal pulmonary venous pattern 2-Dimensional echocardiogram, transesophageal o Acute aortic regurgitation Valve anatomy disrupted Intimal flap Vegetations on valve Pericardial effusion o Chronic aortic regurgitation

Valve anatomy disrupted Estimation of degree of regurgitation Aortic root size and anatomy Left ventricular function

Aortic regurgitation. Chest radiograph in a patient with aortic dissection and acute aortic regurgitation shows a cardiac silhouette of essentially normal dimension

Parasternal long-axis view demonstrating aortic regurgitation jet

Pulsed wave Doppler of the regurgitant jet

Treatment and Management

General o Provide adequate airway management. o Intubate when necessary. o Consider prompt surgical intervention in acute aortic regurgitation. Acute aortic regurgitation o Administer a positive inotrope (eg, dopamine, dobutamine) and a vasodilator (eg, nitroprusside). Rarely, administration of cardiac glycosides (eg, digoxin) for rate control may be necessary. o Avoid beta-blockers in the acute setting. o Administration of vasodilators may be appropriate to improve systolic function and to decrease afterload. Chronic aortic regurgitation o Consider antibiotic prophylaxis for patients with endocarditis when performing procedures likely to result in bacteremia. o Administration of pressors and/or vasodilators may be appropriate. Hemodynamically significant aortic regurgitation may require surgical intervention according to the following criteria: o Cardiac-thoracic ratio >0.64 o Fractional shortening < 25-29% o End-systolic diameter >55 mm o End-diastolic radius to myocardial wall thickness ratio >4.0 o Ejection fraction < 0.45 o Cardiac index < 2.2-2.5 L/min/m2