Aortic Incompetence

Question 1

Aortic Incompetence presentation

Answer 1

This patient has been referred by his GP with ‘a new murmur’. He is asymptomatic. Please examine his cardiovascular system and diagnose his problem.

Question 2

Clinical signs of Aortic Incompetence

Answer 2

1. Collapsing pulse (water-hammer pulse) reflecting a wide pulse pressure, e.g. 180/45
2. Apex beat is hyperkinetic and displaced laterally (TV: thrusting volume‐loaded)
3. Thrill in the aortic area
4. Auscultation:
   - Early diastolic murmur (EDM) loudest at the lower left sternal edge with the patient sat forward in expiration.
   - There may be an aortic flow murmur and a mid diastolic murmur (MDM) (Austin–Flint) due to regurgitant flow impeding mitral opening.
   - In severe AR there may be ‘free flow’ regurgitation and the EDM may be silent.
5. Signs of severity:
   - Collapsing pulse,
   - Third heart sound (S3) and
   - Pulmonary oedema
6. Eponymous signs

Question 3

Auscultation in Aortic Incompetence

Answer 3

• Early diastolic murmur (EDM) loudest at the lower left sternal edge with the patient sat forward in expiration.
• There may be an aortic flow murmur and a mid diastolic murmur (MDM) (Austin–Flint) due to regurgitant flow impeding mitral opening.
• In severe AR there may be ‘free flow’ regurgitation and the EDM may be silent.

Question 4

Eponymous signs in Aortic Incompetence

Answer 4

1. Corrigan’s: visible vigorous neck pulsation
2. Quincke’s: nail bed capillary pulsation
3. De Musset’s: head nodding
4. Duroziez’s: diastolic murmur proximal to femoral artery compression
5. Traube’s: ‘pistol shot’ sound over the femoral arteries

Question 5

Congenital Causes of Aortic Incompetence

Answer 5

1. Bicuspid aortic valve;
2. Perimembranous VSD

Question 6

Acquired Causes of Aortic Incompetence

Answer 6

Valve leaflet:
(Acute): Endocarditis,
(Chronic): 1- Rheumatic fever or 2- Drugs: pergolide, slimming agents

Aortic root
(Acute): 1- Dissection (type A) or 2- Trauma
(Chronic):
1- Dilatation: Marfan’s and hypertension
2- Aortitis: syphilis, ankylosing spondylitis and vasculitis

Question 7

Other causes of a collapsing pulse

Answer 7

1. Pregnancy
2. Patent ductus arteriosus
3. Paget’s disease
4. Anaemia
5. Thyrotoxicosis

Question 8

Investigation in Aortic Incompetence

Answer 8

1. ECG: lateral T‐wave inversion
2. CXR: cardiomegaly, widened mediastinum and pulmonary oedema
3. TTE/TOE:
- Severity: LVEF and dimensions, root size, jet width
- Cause: intimal dissection flap or vegetation
4. Cardiac catheterization: grade severity aortogram and check coronary patency

Question 9

Medical Management of Aortic Incompetence

Answer 9

• ACE inhibitors and ARBs (reducing afterload)
• Regular review: symptoms and echo: LVEF, LV size and degree of AR

Question 10

Indications for Surgery in Aortic Incompetence

Answer 10

Acute:
a. Dissection
b. Aortic root abscess/endocarditis (homograft preferably)
Chronic: Replace the aortic valve when:
a. Symptomatic: dyspnoea and reduced exercise tolerance (NYHA > II) AND/OR
b. The following criteria are met:
1. wide pulse pressure >100 mm Hg
2. ECG changes (on Exercise Tolerance Test)
3. Echo: LV enlargement >5.5 cm systolic diameter or EF <50% Ideally replace the valve prior to significant LV dilatation and dysfunction.

Question 11

Prognosis of Aortic Incompetence

Answer 11

• Asymptomatic with EF > 50% – 1% mortality at 5 years.
• Symptomatic and all three criteria present − 65% mortality at 3 years

Question 12

Guideline recommendations for AVR for asymptomatic Pt with Marfan syndrome

Answer 12

1. Aortic root aneurysm diameter 50 mm or more
2. Aortic root aneurysm 45 mm or more and
   - A family hx of aortic dissection
   - Rapid aneurysm expansion (>3 mm per year)
   - Extreme aortic or mitral valve regurgitation
   - Pregnancy plans