Internal Diseases and Therapy · MU Sofia

16. Diseases of the aortic valve: aortic insufficiency

Covers aortic regurgitation, its chronic and acute forms, and the cusp and aortic root causes behind them. It explains the haemodynamic changes, the classic signs such as the wide pulse pressure, murmurs and peripheral signs, and the echocardiographic severity grading table. It then reviews diagnosis, a differential diagnosis table, medical and surgical treatment with current surgical thresholds, and prognosis.

Inside: 10 sections · 2 labelled pictures · 4 tables · 15 flashcards · 13 min

Topic 16 of 139 in the MU Sofia syllabus for Internal Diseases and Therapy (Medicine, Years 4 and 5). The free AceMed note covers it in 10 sections, about 1,687 words (13 min of reading), with 15 flashcards.

In this note

  1. Definition
  2. Etiology
  3. Pathophysiology and haemodynamics
  4. Classification
  5. Clinical features
  6. Diagnosis
  7. Differential diagnosis
  8. Treatment
  9. Complications
  10. Prognosis

Definition

Aortic regurgitation (AR), or aortic insufficiency, is the backflow of blood from the aorta into the left ventricle (LV) during diastole, because the aortic cusps do not close completely.

  • It results from disease of the cusps themselves or from dilatation of the aortic root and ascending aorta, which pulls the cusps apart even when they are normal.
  • It may be acute (an emergency) or chronic (a long silent course); the two behave very differently.

Aortic regurgitation (left): blood leaks back through the aortic valve into the left ventricle in diastole, adding to the normal inflow from the left atrium. Aortic stenosis (right) is shown for comparison.

Image: “Blausen 0041 AorticValve RegurgitationvsStenosis” by BruceBlaus, CC BY 3.0, via Wikimedia Commons.

Etiology

Disease of the cusps

  • Bicuspid aortic valve: the most common cause in young adults in Europe (prolapse of the larger cusp, often with a dilated aorta).
  • Rheumatic heart disease (usually with mitral disease; the main cause worldwide); calcific degeneration in the elderly (mostly mixed with stenosis).
  • Infective endocarditis: perforation or destruction of a cusp, the classic cause of acute AR.
  • Others: systemic lupus erythematosus, rheumatoid arthritis, drugs (ergot derivatives, fenfluramine), radiotherapy, trauma, a ventricular septal defect or subaortic membrane that damages the cusps.

Disease of the aortic root and ascending aorta

  • Age- and hypertension-related dilatation (annuloaortic ectasia): now a leading cause in the elderly.
  • Hereditary aortopathies: Marfan syndrome, Loeys–Dietz and Ehlers–Danlos syndromes, the aortopathy of bicuspid valve, Turner syndrome, osteogenesis imperfecta.
  • Aortitis: tertiary syphilis, giant cell arteritis, Takayasu arteritis, seronegative spondyloarthritis (ankylosing spondylitis, reactive and psoriatic arthritis), Behçet disease.
  • Aortic dissection involving the ascending aorta (Stanford type A) and chest trauma: causes of acute AR.

Acute AR in short

  • Infective endocarditis, type A aortic dissection, chest trauma, failure of a prosthetic valve.

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