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

• Bicuspid aortic valve
• Senile or degenerative calcific aortic valve disease
• Hypertension
• Idiopthic dialation of the aorta
• Myxomatous degeneration
• Rheumatic fever

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 ❑ Cardiac auscultation ❑ Early diastolic decrescendo murmur ❑ Best heard at the upper left sternal border ❑ Murmur increases with: sitting forward, expiration, handgrip ❑ 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 ❑ 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 ❑ 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 ❑ 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 ❑ For acute AI, a CXR might be normal ❑ Increase cardiac silhouette (if the etiology is aortic dissection) ❑ Widened mediastinum (if the etiology is aortic root dilation) ❑ Pulmonary congestion (suggestive of HF) ❑ Order a ECG ❑ Might see nonspecific changes of ST and T wave (due to LV enlargement) ❑ If aortic dissection is the cause, the right coronary artery may be compromised and you may see ischemic changes in the territory of the right coronary artery

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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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