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Aortic Regurgitation

 

Thank you for asking me to perform a cardiovascular of examine Mr. X, who presented with SOB.

 

The salient finding on examination were a descrescendo early diastolic murmur loudest at the left sternal edge in the 3rd and 4th intercostal space, which increased on expiration, and was associated with a wide pulse pressure, which I believe is consistent with aortic regurgitation.

 

I will now present my findings in full before commenting on differentials, aetiology, severity and complications.

 

The patient was comfortable at rest with normal/increased WOB.

 

On examination of the hands, there was/was no stigmata of IE, clubbing, peripheral cyanosis, or xanthomata.

 

The pulse was ____ and regular/irregular (if irregular, consistent with atrial fibrillation).

 

The blood pressure was ____, with/without a wide pulse pressure (wide if severe).

 

On examination of the face, there was no scleral icterus, conjunctival pallor, xanthelasma, or malar flush. There was no central cyanosis. Dentition was adequate/inadequate.

 

The JVP was/was not elevated at ___ cm above the sternal notch with normal waveforms/prominent A-wave/prominent V-wave.

 

The carotid pulse was collapsing in character with prominent pulsations.

 

On inspection of the praecordium, there were/were not scars and nil obvious deformity.

 

On palpation, the apex beat was fifth intercostal space mid-clavicular line / displaced and volume loaded (diastolic and hyperkinetic - forceful but unsustained). There were/were not any palpable thrills. There was/was not a left parasternal heave.

 

There was a normal first and normal/soft second heart sound (soft A2 if severe), with physiological/fixed/reversed splitting, with no additional third or fourth heart sound/third/fourth heart sound (additional third heart sound if severe).

 

On auscultation, as aforementioned, there was a decrescendo early diastolic murmur loudest in the third and fourth intercostal space, which increased on expiration. (If nil radiation, state there was no radiation to the axilla or carotids). It was accentuated on sitting forward. It decreased intensity with the valsalva manoeuvre .There was/was not an associated systolic murmur, which may represent concominant aortic stenosis, or a flow murmur.

 

 

On further examination, there was/was not evidence of left and right heart decompensation with sacral oedema or peripheral oedema, and vesicular breath sounds/bibasal inspiratory crackles. There was/was not a pulsatile liver, and nil gross ascites.

 

In summary, my findings are consistent with aortic regurgitation.

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Other differentials include:

  • Pulmonary regurgitation

  • Mitral stenosis

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In terms of severity:

  • In terms of signs of severity, there was/was not a collapsing pulse, a wide pulse pressure, prolonged length of decrescendo murmur, a third heart sound, a soft aortic component of the second heart sound, an Austin-Flint murmur (a diastolic rumble caused by limitation to mitral inflow by the regurgitation jet), or evidence of left ventricular failure.

 

In terms of the aetiology of chronic AR:

  • ¨Valvular/leaflet:

    • Connective tissue disease - (especially AS) - can cause both valve and root issues

    • Congenital - bicuspid valve

    • Rheumatic heart disease is less likely as it is rarely isolated

  • Aortic root:

    • There were no features of Marfan’s syndrome

    • Connective tissue disease

    • Old age

    • Idiopathic

  • Acute

    • Valvular - IE

    • Root - Marfan’s, dissecting aneurysm

  • I could not ascertain the exact aetiology, however differentials include degenerative changes.

 

I would proceed from here by:

  • Confirming my diagnosis with an echocardiogram

 

What are the differentials for a wide pulse pressure?

  • The difference is determined by the compliance of the aorta as well as the ventricular stroke volume

  • AR

  • Arteriosclerosis and less compliant vessels

  • Hyperdynamic circulation - distributive shock, anaemia

 

What are the differentials for a small pulse pressure?

  • This indicates a low stroke volume

  • AS

  • CCF

  • Tamponade

  • MS

  • Trauma/significant blood loss (leading to insufficient preload)

 

What are the ECG findings?

  • ECG - LV hypertrophy (35mm V1 and V5/V6, left strain pattern - ST depression V3-V6)

 

What are the indications for surgery?

  • Class 1 = severe AR (regurgitant fraction > 50%, regurgitant volume > 60ml, holodiastolic aortic flow reversal, vena contracta > 0.6cm, effective regurgitant orifice > 0.3cm) and symptoms

  • Also considered if severe and asymptomatic, but if LVEF < 55%

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