Rapid Review·Cardiovascular
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Valvular Heart Disease
T1Must knowAortic Regurgitation
Focus on
Chronic AR is the wide pulse pressure and its dozen eponyms plus an early diastolic decrescendo murmur; the ventricle dilates for years, and surgery comes with symptoms or an EF below 55%. Acute AR (endocarditis, dissection) is the opposite — a normal-sized ventricle, a short soft murmur, flash pulmonary edema, and an emergency operation.
Key takeaways
What it is and what causes it
What this shows
Aortic regurgitation
the aortic valve does not close fully, so blood refluxes from the aorta into the left ventricle in diastole.Acute causes
infective endocarditis, aortic dissection, chest trauma.Chronic valve disease
a bicuspid valve (early-onset disease) or rheumatic disease (most common in lower-income countries).Chronic aortic root disease (dilation or aneurysm)
syphilitic aortitis, connective tissue disease (Marfan syndrome).Clinical features
Acute regurgitation
sudden severe dyspnea with rapid decompensation and pulmonary edema.Chronic regurgitation, a hyperdynamic circulation
a wide pulse pressure with five signs.- A "water hammer" pulse (rapid rise and fall).
- Head or uvula bobbing.
- Abrupt carotid distension and collapse.
- "Pistol-shot" femoral pulses.
- Visible capillary pulsations in the nail beds.
What this shows
The murmur
an early diastolic blowing decrescendo murmur at the left sternal border (third left space) for valvular disease, or at the second right space for root disease.Other chronic signs
left heart failure, an S3 gallop, and an Austin Flint murmur.Diagnosis
Transthoracic echocardiography
confirms it.Chest radiograph
differs with the speed of onset.- Chronic regurgitation: an enlarged left ventricle.
- Acute regurgitation: the ventricle is normal in size and the lungs show edema.
Management
Acute regurgitation
emergency valve replacement or repair.Chronic regurgitation
valve replacement for severe or highly symptomatic disease, or when asymptomatic with a left ventricular ejection fraction under 55 percent.- Manage heart failure medically meanwhile.
| Acute | Chronic | |
|---|---|---|
| Causes | Endocarditis, aortic dissection, chest trauma | Bicuspid or rheumatic valve, aortic root disease |
| Presentation | Sudden dyspnea, pulmonary edema, rapid decompensation | Wide pulse pressure signs, murmur, slow left heart failure |
| Left ventricle on the radiograph | Normal size | Enlarged |
| Treatment | Emergency valve surgery | Surgery when severe or symptomatic, or ejection fraction under 55 percent |
A patient with fever and a new early diastolic murmur suddenly develops pulmonary edema; the chest radiograph shows a normal-sized heart. What is the diagnosis and the treatment, and how does this differ from the chronic form?
Acute aortic regurgitation from infective endocarditis: the ventricle has had no time to dilate, so it is normal in size and the lungs flood. It needs emergency valve replacement or repair. Chronic regurgitation instead gives an enlarged ventricle and a wide pulse pressure, and goes to surgery when severe, symptomatic, or with an ejection fraction under 55 percent.
How it's tested
A tall man with long fingers, a bounding pulse, head nodding with each beat and an early diastolic murmur at the right sternal border: aortic regurgitation from Marfan root dilation — echo and aortic imaging.
An apical diastolic rumble in a patient with AR and no opening snap: Austin Flint murmur, not mitral stenosis.
Fever, new diastolic murmur and sudden pulmonary edema with a normal-sized heart on the film: acute AR from endocarditis — emergency valve surgery; no balloon pump.
Asymptomatic severe AR with an EF of 52%: operate — the threshold in AR is 55%, not 50%.
Which peripheral sign belongs to which name: Corrigan (water-hammer pulse), de Musset (head bobbing), Quincke (nail-bed pulsation), Traube (pistol-shot femorals), Duroziez (femoral to-and-fro murmur), Müller (uvula), Hill (popliteal–brachial gradient).
Go deeper
Guidelines: 2020 ACC/AHA Valvular Heart Disease Guideline
Related Step 2 pages: Aortic Stenosis, Bicuspid Aortic Valve, Aortic Dissection, Infective Endocarditis, Thoracic Aortic Aneurysm, Heart Sounds & Murmurs
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