Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ 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 ... Your Access profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free a profile for additional features.