Aortic Regurgitation (Insufficiency) Explained Clearly

Aortic Regurgitation (Insufficiency) Explained Clearly

well welcome to another MedCram
lecture we’re gonna talk about a or decree Gurjit ation we’re going to talk
about the causes the pathophysiology clinical features physical diagnosis
treatment and when we should do surgery so specifically we’re talking about the
aortic valve and what regurgitation simply means is that the valve is
incompetent and we get backflow and what are the causes of that and what do we do
about it now in terms of causes you can kind of break it down into those less
than 50 and those greater than 50 those less than 50 that have a otic
insufficiency are usually due to post inflammatory those after the age of 50
have usually to do with aortic root dilatation and so specifically post
inflammatory the type of things that you want to think about our rheumatic heart
disease or our H D rheumatic heart disease infectious endocarditis think
about syphilis and then in terms of a otic root dilatation think about other
things think about age-related or the other one
to think about is more fans Marfan syndrome as you may know is where
they’re very tall they’ve got long legs long legs and long arms and they can get
Eric root dilatation in terms of other things to think about is think about
lupus or SLE and this thing called ankylosing spondylitis ankylosing spondylitis that’s where they
get the bamboo spine okay so the pathophysiology of this is that this
valve the aortic valve becomes leaky and blood goes back into the left ventricle
and this occurs of course during diastole
so it’s diastolic that means between s2 and then at the beginning of s1 again as
a result of that it’s going to cause the left ventricle to become bigger because
blood is coming back in it’s going to increase the preload and as a result of
the fact that it’s pumping more blood you’re also gonna get hypertrophy so you
see it’s in diastole you gotta get a murmur diastolic murmur okay that
diastolic murmur because it’s on the left side anything that increases the
left side is going to cause the diastolic murmur to get bigger so what
are those things that causes the left side to get bigger would be any kind of
straining okay anything that increases afterload and what’s gonna cause it to
get smaller the the murmur to get smaller well anything that decreases the
left side of the heart so that would be a valsalva or anything that causes
dilation of the peripheral vasculature that would be like amyl nitrate now as
you may recall this a Horta kind of works as what the german word is like a
wind Kessel basically it expands during systole and then as diastole occurs it
contracts as it contracts it kind of ends ends up like being a pump by itself
pumping the blood forward however in a or decree Gurjit ation instead of that
blood going forward the blood goes backwards and backwards here into the
left ventricle so you’re gonna get left ventricular hypertrophy and you’re gonna
get an increase in the left ventricular and diastolic volume now in
addition to that because during diastole you’ve got all this blood coming back
into the left ventricle you’re going to see a low diastolic blood pressure and
because there’s more blood in the left ventricle right before systole more
blood is going to be ejected out and so therefore you’re going to see an
increase in systolic blood pressure this is known as a increase in the pulse
pressure which sets up some pretty interesting physical exam findings so in
other words when you take the blood pressure and you take the systolic over
the diastolic you’re going to see that the difference between those two
pressures is going to go up so let’s quickly talk about some of the clinical
features that you might see as we mentioned you’re going to see in it
you’re gonna see LVH left ventricular hypertrophy or a left ventricular
end-diastolic volume which is increased the other thing that you might see is
syncope just like we saw in aortic stenosis however there’s a couple of
reasons why you might see that here the first is that if the diastolic pressure
is so low that you can’t maintain an adequate perfusion you’re gonna see
syncope but the other thing that you’re gonna see here and this is a little bit
more subtle as you might see angina now why is that you think you should know is
that the coronaries come off of this area in the aorta and what drives blood
pressure or what drives perfusion in these very important coronary arteries
is actually the diastolic blood pressure okay because flow occurs mainly through
the time period of diastole and so during diastole is when you’re gonna get
this pressure here pushing blood through the arteries to the myocardium if your
diastolic blood pressure is low because it’s instead of going into the
coronaries it’s going back here into the left ventricle you’re gonna get a
decreased coronary artery perfusion pressure and as a result you’re gonna
get angina now one thing I will say is that when you look at systole through
the cardiac cycle from one period to the next period let’s say we start at s1 s2
is fairly short after it and then you’ve got diastole so this is systole and this
is diastole okay now where is this regurgitant flow occurring it’s
occurring between s2 and the next s 1 which is diastole something that you may
not know is that when you speed up the heart rate this period of time between
s1 and s2 doesn’t really change much it stays the same
what does change is the time period of diastole it gets shorter and shorter to
allow for a faster heart rate the point is is that as the heart rate speeds up
diastole becomes shorter and shorter and therefore the time for regurgitation
becomes less and less so as a result of this you usually see that tachycardia is
well tolerated okay so tachycardia is well tolerated in
a or t’k insufficiency okay let’s talk about physical diagnosis what you’ll see
is because this is getting larger you’ll see the apical impulse is going to be
displaced downward and to the left and then the actual diastolic murmur is
going to be a high-pitched murmur heard at the left sternal border and it’s
going to actually be heard quite well if you have the patient lean forward so if
they’re sitting on a table have them lean forward and then place the
stethoscope there if that will bring that murmur closer to the chest wall and
you’ll be able to hear it much better now an interesting thing that occurs is
something called the Austin Flint murmur it’s actually one guy just with two
different names Austin Flint is the murmur that
occurs when blood goes back across the aortic valve and because it’s flowing in
here it tends to keep this mitral valve closed or at least almost closed now
remember that blood is supposed to be going from the left atrium into the left
ventricle during diastole and if this blood from the aorta is coming in and
closing that valve or at least I try and attempt to to close that valve you’re
gonna get a functional hey Ord art mitral stenosis that is the murmur of
the Austin Flint and that’s a rumbling okay that’s a rumbling sound so you
might hear a high-pitched murmur and then a rumbling throughout diastole that
could be an Austin Flint remember that’s associated with an aortic regurgitation
murmur that’s the from the vibrations now we talked before about this
increased pulse pressure so that the systolic blood pressure is high and the
diastolic is low that it causes a change or a pulse pressure that’s gonna make
the pulse pressure go up from our equation as a result of this you’ll see
that that people’s pulses are very bounding and they’re very large and
amplitude and there’s a number of things that are found on physical exam you may
want to know some of the names but they’re not essential so this is known
as a corridor pulse okay if you’ve listened to this or if you feel this in
the femoral area it’s known as a pistol shot okay that’s the femoral if you hear
a diastolic bruit over the femoral area so a diastolic bruit that’s known as the
Rozier’s sign D you are oh z IE z de rozier sy okay now if you see a bobbing
head that’s known as du mu SE sign de spaced em USS ET and interesting they
used to think that Abraham Lincoln had Marfan’s disease because they felt
number one he was very tall and also that whenever they looked at pictures of
him they found that his head was kind of a blur and they needed to take long
exposures back in those days and because of this Dumas a sign that he must have
had from aortic regurgitation that they felt that this was proof that he had
Marfan’s disease I think the jury was out on that they don’t really know if he
did or not it or maybe the photographer was just a bit too shaky anyhow just a
little way to put all that together another thing is quickies pulse quickies
pulse is when you look at the nail bed of your fingers and you see that there’s
a blushing and blanching so these are all signs of aortic insufficiency of
course you’re going to order an echocardiogram to make the final
diagnosis on that but interesting nonetheless so again how are you going
to make the diagnosis and today’s day and age it’s going to be echocardiogram
they’re gonna be able to look at the valve they’ll be able to tell you how
much regurgitation there is and some of the things that might lead you to think
is a chest x-ray what are you gonna see on a chest x-ray well if it’s severe
you’ll see this left ventricle and large you will also see pulmonary vascular
congestion possibly obviously a cardiologist before surgery is going to
do cath where they actually float in a catheter into this area they can release
contrast and they can see how much is going back and forth and they can
actually calculate the regurgitant volume in terms of treatment you’re
going to want to make sure most the blood is going out
so the way you do that is with loop diuretics to get rid of some of this
excess fluid and then you want to reduce afterload and that would be with
something like nitrates or hydralazine you don’t want to use things like beta
blockers that slow the heart rate down because remember if you slow the heart
rate down it’s going to increase the time in diastole this is going to
increase regurgitation and it may steal away some of your perfusion from your
coronary arteries you actually you actually might actually see a reversal
to flow in the coronary as if if the regurgitation is that bad then your
patients will start having angina okay so surgery when you do surgery basically
when you start to see left ventricular decompensation so when you see the
ejection fraction going down when you see more congestive heart failure it’s
really a cardiologist call but that’s when you get referral and of course
you’re going to get a aortic valve replacement you can either get a bio
prosthetic valve which does not require anticoagulation or you’ll get a
mechanical valve which does require anticoagulation thank you for joining us you

6 Replies to “Aortic Regurgitation (Insufficiency) Explained Clearly”

  1. the definition of austin flint has recently changed its now believed that its caused by the regurgitant jet of blood abutting against the left ventricular endocardium…

  2. I have heard it is better to keep your MV rather than replace it. What r your thoughts on doing this if the MV is still savable??
    I know the age, condition, etc play a role in the decision, but I would rather keep my parts if possible.
    I think I had a heart murmur when I was under 50ty. then I was told I didn't have it. could it have gone away & come back??
    Do U know of any natural way to get rid of the stiffness of the MV?
    Mine is getting stiff & thicker as is my LV.
    I have it mind now, but I am quite old. I worry about having surgery on it when I am even older.
    What can I do to keep it from becoming worse than it already is?
    Mild isn't supposed to be surgery time yet, but I fear to wait till it is bad. I may be too old & too weak to survive very long after it is fixed…
    A friend of mine had the pig valve & died within a year after having it…
    Yes, I know everyone is different, but I fear I could have the same bad luck as she had.
    Do U know any top heart Drs in LA, Ca? taking Medicare???
    I did know about Dr. David Cannom.
    he is world famous.
    I saw him years ago about some other issues I was having.
    He is 78 yrs old now…
    Do U know any heart docs who specialize in the newest successful MV surgeries?
    I wish to keep my valve if possible.
    Thanks for making it very easy to follow…
    I also like some of the names.
    1 would make a great dog's name too.
    The quinkes or something like that… I thought it would make a great dogs name. here Quinkes

  3. Can anyone explain me about diastolic blood pressure ?? I'm very confused

    Diastole means the period between 2 heart beats where heart is not ejecting the blood but here during regurgitation the blood flows back into ventricle which will lead to increase in pressure,right ??

    So why does Diastolic blood pressure decrease during regurgitation

    Someone please explain me

  4. Since about 3 people asked about this in the comments, I thought to post this.

    Diastolic blood pressure is determined by the elasticity and recoil (of the blood left in the aorta after ejection) on a closed aortic valve, which generates pressure. Therefore, the reason why diastolic blood pressure decreases in aortic regurgitation is because the malcoaptation of the valve (inability to completely close) decreases the pressure on the valve and the aortic walls when it is supposed to be closed. Think of a water hose as an analogy and for simplicity sake, disregard the direction of water flow. When your thumb is over a waterhose completely, this creates an increase in pressure behind your thumb. You may even see this as a dilation in the water hose somewhere distally. Now, if you slide your thumb over so that a little water can trickle out, you'd notice that while there is still pressure built up behind your thumb, it is significantly less. That decrease in pressure is similar to the diastolic pressure in aortic regurgitation. Because not as much blood is banging against the closed aortic valve, and is instead trickling past the malcoaptated valve, there is a proportionate decrease in pressure against the aortic valve and the walls of the aorta. Hopes this helped somewhat!


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