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| __NOTOC__
| | #Redirect [[Aortic regurgitation overview]] |
| {{Aortic insufficiency}}
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| {{CMG}}; {{AE}} {{RT}}
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| ==Natural History==
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| There are two main parameters that reflect the overall outcome in patients with aortic insufficiency:
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| *[[Ejection fraction]] (the lower the [[ejection fraction]], the poorer the outcome)
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| *End systolic diameter
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| [[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]].
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| ==Diagnosis==
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| ===Symptoms===
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| Acute aortic insufficiency may present with the following symptoms:
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| * Sudden onset of severe breathlessness ([[dyspnea]])
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| * [[Chest pain]] (chest pain occurs when [[aortic dissection]] is the cause of the insufficiency).
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| Chronic aortic insufficiency causes:
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| * [[Exertional dyspnea]]
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| * [[Orthopnea]]
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| * [[Paroxysmal nocturnal dyspnea]]
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| * [[Palpitations]]
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| 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]]).
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| ===Physical Examination===
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| * Bounding [[pulse]]s may be present.
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| * [[Head]] nodding ([[de Musset's sign]]) - rhythmic nodding or bobbing of the head in synchrony with the beating of the heart.
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| * [[Capillary]] pulsations ([[Quincke's sign]]) - pulsation of arteriolar and venous plexuses of the nail bed causing alternate blanching and flushing.
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| * [[Corrigan's pulse]] - A rapid upstroke and collapse of the [[carotid artery]] [[pulse]].
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| * [[Duroziez's sign]] - 'pistol' shot sounds (audible [[diastolic murmur]] heard over the [[femoral artery]])
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| * Early diastolic murmur best heard in the right second intercostal space. The murmur may be soft in acute AR.
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| * S<sub>3</sub> and S<sub>4</sub> may be heard.
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| ===Imaging===
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| [[Echocardiography]] is used to assess the following parameters:
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| *[[End-diastolic diameter]]
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| *[[End systolic diameter]]
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| *[[Ejection fraction]]
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| [[Echocardiography]] can also be used to assess the [[ascending aorta]] (root) and/or valve causes of insufficiency.
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| Echocardiographic findings correlated with severe AR include:
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| * AR color jet dimension/left ventricular outflow tract diameter >60%
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| * Flow reversal in proximal [[descending thoracic aorta]]
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| * Regurgitant volume > 60 ml
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| * Regurgitant fraction > 55%
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| 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]].
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| *Treadmill testing in aortic regurgitation is used to objectively assess the patient's exercise capacity.
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| *[[Magnetic resonance angiogram]] ([[MRA]]) and [[CT]] are used to scan the entire [[aorta]] when [[bicuspid aortic valve]] is present.
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| ==Treatment==
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| ===Acute Severe Aortic Insufficiency===
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| *Urgent surgical intervention is indicated in the cases of type A [[aortic dissection]] and acute prosthetic AR.
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| *[[Nitroprusside]] and [[ionotropes]] can be used to maintain [[blood pressure]].
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| *Treatment options that are contraindicated include:
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| **[[Intra aortic balloon pump]]
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| **[[Pressor]]s
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| **[[Beta blockers]]
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| ===Chronic Aotic Insufficiency===
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| *[[Vasodilator]] therapy is indicated for the treatment of severe chronic aortic insufficiency in:
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| **Patients with symptoms and/or left ventricular [[ejection fraction]] ≤ 50% and who are not candidates for [[aortic valve replacement]].
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| **Asymptomatic patients with [[AR]] and [[hypertension]].
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| *[[Vasodilator]] therapy is not indicated for other patients with AR.
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| ===Indications for Surgery===
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| Indications for surgery in aortic insufficiency include:
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| * Very severe insufficiency
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| * Any symptoms
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| * [[Ejection fraction]] < 50%
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| * End systolic dimension > 50 mm
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| ==References==
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| {{reflist|2}}
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| [[Category:Disease]]
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| [[Category:Cardiology]]
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| [[Category:Valvular heart disease]]
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| [[Category:Congenital heart disease]]
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| [[Category:Surgery]]
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| [[Category:Cardiac surgery]]
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| [[Category:Emergency medicine]]
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| [[Category:Intensive care medicine]]
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| [[Category:Up-To-Date cardiology]]
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| [[Category:Up-To-Date]]
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| {{WH}}
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| {{WS}}
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