View source for Aortic regurgitation general approach to aortic insufficiency

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{{Aortic insufficiency}}
{{CMG}}; {{AE}} {{RT}}

==Natural History==
There are two main parameters that reflect the overall outcome in patients with aortic insufficiency:
*[[Ejection fraction]] (the lower the [[ejection fraction]], the poorer the outcome)
*End systolic diameter

[[Left ventricular dysfunction]] develops in patients with aortic insufficiency after decades of the onset of the symptoms. This lag period is longer than that of [[mitral regurgitation]].

==Diagnosis==
===Symptoms===
Acute aortic insufficiency may present with the following symptoms:
* Sudden onset of severe breathlessness ([[dyspnea]])
* [[Chest pain]] (chest pain occurs when [[aortic dissection]] is the cause of the insufficiency).

Chronic aortic insufficiency causes:
* [[Exertional dyspnea]]
* [[Orthopnea]]
* [[Paroxysmal nocturnal dyspnea]]
* [[Palpitations]]

Patients having [[bicuspid aortic valve]] should be evaluated for [[coarctation of aorta]] if [[hypertension]] is present and for [[dissection of aorta]] if [[chest pain]] is present. Therefore the entire [[aorta]] should be scanned either by [[magnetic resonance angiogram]] ([[MRA]]) or [[computed tomography]] ([[CT]]).

===Physical Examination===
* Bounding [[pulse]]s may be present.
* [[Head]] nodding ([[de Musset's sign]]) - rhythmic nodding or bobbing of the head in synchrony with the beating of the heart.
* [[Capillary]] pulsations ([[Quincke's sign]]) - pulsation of arteriolar and venous plexuses of the nail bed causing alternate blanching and flushing.
* [[Corrigan's pulse]] - A rapid upstroke and collapse of the [[carotid artery]] [[pulse]].
* [[Duroziez's sign]] - 'pistol' shot sounds (audible [[diastolic murmur]] heard over the [[femoral artery]])
* Early diastolic murmur best heard in the right second intercostal space. The murmur may be soft in acute AR.
* S<sub>3</sub> and S<sub>4</sub> may be heard.

===Imaging===
[[Echocardiography]] is used to assess the following parameters:
*[[End-diastolic diameter]]
*[[End systolic diameter]]
*[[Ejection fraction]]

[[Echocardiography]] can also be used to assess the [[ascending aorta]] (root) and/or valve causes of insufficiency.

Echocardiographic findings correlated with severe AR include:
* AR color jet dimension/left ventricular outflow tract diameter >60%
* Flow reversal in proximal [[descending thoracic aorta]]
* Regurgitant volume > 60 ml
* Regurgitant fraction > 55%

If the color flow on [[echocardiography]] is solely taken into consideration during the evaluation of aortic regurgitation, echocardiographic findings might underestimate or overestimate the severity of the regurgitation. Thus, it is recommended to use [[cardiac catheterization]] as an imaging modality. When discrepancy exists between the findings of [[echocardiography]] and that of the [[cardiac catheterization]], it is recommended to do a left [[ventriculogram]].

*Treadmill testing in aortic regurgitation is used to objectively assess the patient's exercise capacity.
*[[Magnetic resonance angiogram]] ([[MRA]]) and [[CT]] are used to scan the entire [[aorta]] when [[bicuspid aortic valve]] is present.

==Treatment==
===Acute Severe Aortic Insufficiency===
*Urgent surgical intervention is indicated in the cases of type A [[aortic dissection]] and acute prosthetic AR.
*[[Nitroprusside]] and [[ionotropes]] can be used to maintain [[blood pressure]].
*Treatment options that are contraindicated include:
**[[Intra aortic balloon pump]]
**[[Pressor]]s
**[[Beta blockers]]
===Chronic Aotic Insufficiency===
*[[Vasodilator]] therapy is indicated for the treatment of severe chronic aortic insufficiency in:
**Patients with symptoms and/or left ventricular [[ejection fraction]] ≤ 50% and who are not candidates for [[aortic valve replacement]].
**Asymptomatic patients with [[AR]] and [[hypertension]].
*[[Vasodilator]] therapy is not indicated for other patients with AR.
===Indications for Surgery===
Indications for surgery in aortic insufficiency include:
* Very severe insufficiency
* Any symptoms
* [[Ejection fraction]] < 50%
* End systolic dimension > 50 mm

==References==
{{reflist|2}}
[[Category:Disease]]
[[Category:Cardiology]]
[[Category:Valvular heart disease]]
[[Category:Congenital heart disease]]
[[Category:Surgery]]
[[Category:Cardiac surgery]]
[[Category:Emergency medicine]]
[[Category:Intensive care medicine]]
[[Category:Up-To-Date cardiology]]
[[Category:Up-To-Date]]
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