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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • After a long asymptomatic period, presentation with heart failure, arrhythmias, or angina

  • Wide pulse pressure with associated peripheral signs

  • Diastolic decrescendo murmur at left sternal border

  • Left ventricular (LV) dilation and hypertrophy with preserved function

  • Diagnosis confirmed and severity estimated by Doppler echocardiography or aortography

GENERAL CONSIDERATIONS

  • Caused by diseases of the valve leaflets or aortic root (dilatation), or high blood pressure

  • Root diseases: Marfan’s syndrome, cystic medial necrosis, aortic dissection, syphilis, and connective tissue diseases such as ankylosing spondylitis

  • Leaflet diseases: rheumatic, infectious endocarditis, congenital and connective tissue diseases such as rheumatoid arthritis

  • Causes a volume load on the LV, which, if progressive, eventually leads to LV dysfunction

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Most remain asymptomatic for years

  • Palpitation: arrhythmias or awareness of forceful heartbeat

  • Angina pectoris, mechanism: low diastolic pressure plus LV hypertrophy

  • Dyspnea and fatigue when LV dysfunction supervenes

  • Congestive heart failure symptoms: orthopnea and edema

PHYSICAL EXAM FINDINGS

  • Bounding peripheral pulses with wide pulse pressure

  • Enlarged apical impulse

  • Auscultation: LV gallops, high-pitched decrescendo murmur at the right second (aortic area) or left third intercostal space, systolic ejection murmur, occasional apical diastolic rumble (Austin Flint murmur)

DIFFERENTIAL DIAGNOSIS

  • Pulmonic regurgitation associated with high pulmonary pressures (Graham Steell murmur)

  • Patent ductus arteriosus; at fast heart rates, the systolic and diastolic murmurs of aortic regurgitation may resemble a continuous murmur

  • Mitral stenosis mimicking an Austin Flint murmur

  • Arteriovenous malformation with wide pulse pressure

  • Arteriovenous fistula near heart with continuous murmur

  • Left anterior descending coronary artery stenosis

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Tests pertinent to potential causes or prognosis:

    • – Antinuclear antibody test for connective tissue disease

    • – B-type natriuretic peptide levels to assess the degree of volume loading.

ELECTROCARDIOGRAPHY

  • LV hypertrophy

  • Left atrial enlargement

  • Ventricular arrhythmias (ectopic beats)

STRESS TESTING

  • Treadmill exercise is useful to evaluate patients with equivocal symptoms or guide those interested in participating in athletic activities

  • Semi-supine bicycle exercise echocardiography is useful for determining the effect of exercise on estimated pulmonary artery systolic pressure (PASP); rises in PASP to > 50 mm Hg suggest hemodynamically significant aortic regurgitation

IMAGING STUDIES

  • Chest x-ray: cardiomegaly, aortic dilatation, pulmonary vascular congestion

  • Echocardiography: LV and left atrial enlargement, eccentric ventricular hypertrophy

  • Doppler echocardiography; severity can be assessed by:

    • – Width of color flow jet at its origin relative to LV outflow tract diameter

    • – Calculated regurgitant volume and fraction of forward flow from pulsed-wave Doppler comparison of LV outflow to mitral valve inflow

    • – Regurgitant pressure half-time by continuous-wave Doppler

    • – More severe aortic regurgitation showing a larger, denser jet and backward ...

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