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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Usually due to aortic dissection, endocarditis, or trauma

  • Sudden, severe dyspnea, orthopnea, and weakness

  • Signs of pulmonary edema

  • Soft S1 and S3 and short decrescendo diastolic murmur at the base

  • Characteristic Doppler echocardiographic findings:

    • – Confirm aortic regurgitation (color jet)

    • – Estimate its severity (short pressure half-time)

    • – Estimate left ventricular pressure (premature closure of mitral valve, diastolic mitral regurgitation)

GENERAL CONSIDERATIONS

  • Sudden, severe aortic regurgitation does not allow time for the left ventricle to adapt

  • The acute volume load on a relatively noncompliant left ventricle leads to immediate and marked increases in filling pressures, which:

    • – Are transmitted to the lungs

    • – Result in acute pulmonary edema

  • Because left ventricular diastolic volume is initially normal, total stroke volume does not increase and forward stoke volume decreases, resulting in:

    • – Sympathetic stimulation

    • – Peripheral vasoconstriction

    • – Worsening of aortic regurgitation

  • Acute aortic regurgitation is usually due to:

    • – Leaflet abnormalities that cause sudden disruption or prolapse such as infective endocarditis

    • – Other vasculitides or trauma

    • – Occasionally, sudden root dilatation, as occurs with aortic dissection

    • – Ruptured sinus of Valsalva aneurysm—most common congenital cause

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Sudden, severe dyspnea, orthopnea, and weakness

  • Rapid progression to hemodynamic collapse

PHYSICAL EXAM FINDINGS

  • Normal pulse pressure

  • Possible hypotension

  • Pulmonary rales

  • Normal left ventricular impulse

  • Auscultation findings:

    • – Soft S1 due to premature closure of the mitral valve

    • – S3

    • – Short high-pitched aortic diastolic murmur

  • Absent pulses if due to aortic dissection

DIFFERENTIAL DIAGNOSIS

  • Other causes of acute pulmonary edema

  • Aorto-left ventricular fistula due to endocarditis

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • CBC: Elevated white blood cell count and positive blood cultures if due to endocarditis

  • Specific tests for various vasculitides may be helpful, such as antinuclear antibodies

  • Brain natriuretic peptide levels elevated in proportion to severity and may aid in decision for surgery

ELECTROCARDIOGRAPHY

  • Sinus tachycardia

  • Atrioventricular nodal disease if cause is infective endocarditis

IMAGING STUDIES

  • Chest x-rays to detect:

    • – Wide mediastinum if aortic dissection

    • – Pulmonary edema

    • – Broken ribs if due to trauma

  • Echocardiography to detect:

    • – Structural abnormalities of the valve or aortic root

    • – Early closure of the mitral valve

  • Transesophageal echo better if endocarditis or aortic dissection considered

  • Doppler echocardiography—color flow identification of the leak:

    • – If severe, a truncated continuous-wave Doppler signal of aortic regurgitation is found, because pressure between the aorta and the left ventricle equilibrates rapidly; this results in a short pressure half-time by continuous-wave Doppler of the jet

    • – There may be diastolic mitral regurgitation

  • MRI or CT scan useful to assess for dissection

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