Sandbox/AIRSG

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Overview

Aortic insufficiency refers to the retrograde or backward flow of blood from the aorta into the left ventricle during diastole.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Aortic dissection
• Infective endocarditis

Common Causes

• Rheumatic fever
• Bicuspid aortic valve
• Senile or degenerative calcific aortic valve disease
• Hypertension

Management

Acute aortic insufficiency

Shown below is an algorithm summarizing the approach to acute aortic insufficiency (AI)

Characterize the symptoms: ❑ Sudden and severe dyspnea ❑ Chest pain ❑ Palpitations

Inquire about past medical history: ❑ Previously healthy ❑ Cardiac disease: ❑ Hypertension ❑ Bicuspid aortic valve ❑ Rheumatic fever ❑ Pulmonary disease

Examine the patient: ❑ Vitals ❑ Heart rate: tachycardia may be present to compensate for a reduced stroke volume ❑ Blood pressure: wide pulse pressure (systolic BP - diastolic BP ≥ 60 mmHg) ❑ Pulses ❑ Corrigan's pulse:A rapid upstroke and collapse of the carotid artery pulse {{#ev:youtube|rh7_MnjrOAY|300}} ❑ Cardiac auscultation ❑ Early diastolic decrescendo murmur ❑ Best heard at the upper left sternal border ❑ Murmur increases with: sitting forward, expiration, handgrip {{#ev:youtube|HtDzHWNYKQM|300}} ❑ An S3 gallop may be present (suggestive of left ventricular dysfunction) ❑ Austin Flint murmur: a soft mid-diastolic rumble, best heard at the cardiac apex {{#ev:youtube|y5CcncRHl38|300}} ❑ Traube's sign: Systolic and diastolic murmurs described as 'pistol shots' heard over the femoral artery when it is gradually compressed Search for other signs suggestive of aortic insufficiency ❑ Müller's sign: systolic pulsations of uvula ❑ de Musset's sign: head bobbing with each heart beat {{#ev:youtube|HLMqkHZ-Mvo|300}} ❑ Hill's sign: A ≥ 20 mmHg difference in popliteal and brachial systolic cuff pressures, seen in chronic severe AR. Considered to be an artifact of sphygmomanometric lower limb pressure measurement ❑ Quincke's sign: Pulsation of the capillary bed in the nail {{#ev:youtube|9m_0RAQDFHM|300}} ❑ Pulmonary auscultation: search for rales (seen when congestive heart failure has developed)

Order imaging studies: ❑ Order an echocardiography, assess: ❑ Valve morphology ❑ Pressure gradient ❑ Aortic valve area ❑ Ejection fraction ❑ LV wall thickness and motility ❑ Order a CXR, look for: ❑ Cardiomegaly ❑ Valve calcification ❑ Dilatation of ascending aorta ❑ Pulmonary congestion ❑ Order a ECG, look for: ❑ LVH ❑ Left atrium enlargement ❑ LBBB ❑ AF (in late disease)

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Chronic aortic insufficiency

Shown below is an algorithm summarizing the approach to chronic aortic insufficiency

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Do's

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Don'ts

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References

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