Aortic Regurgitation Examination Proceed as per cardiovascular examination On detecting AR, to examine eyes for Argyll-Robertson pupil and

auscultate the femorals for pistols shots (Traube sign) and Duroziez sign. Presentation Sir, this patient has aortic regurgitation that is severe. My findings are: Presence of a high-pitched early diastolic murmur heard best at the left lower sternal edge and is loudest at end expiration with the patient sitting forwards. It is a grade 4/6 murmur and is associated with a diastolic thrill. It is severe as the murmur is of a long duration associated a soft second heart sound with a S3 present. There is also an Austin Flint murmur with presence of a mid diastolic murmur heard at the apex not associated with an opening snap. The apex beat is displaced at the 6th IC anterior axillary line and is thrusting in nature. This is associated with evidence of CHF with bibasal crepitations, raised JVP at 4 cm with a prominent V wave as well as bilateral peal edema. Peripheral examination showed no evidence of IE. The pulse is bounding and collapsing in nature at a rate of 90 bpm in SR. There is no RR or RF delay to suggest coarctation of the aorta. In addition, quinkes sign was negative. There was no conjunctival pallor but Corrigans sign and brachial dance were present. Mullers sign, Duroziez and Traubes signs were not detected. In terms of etiology, there is no evidence of symmetrical deforming polyarthropathy to suggest RA and patient does not have a Marfanoid habitus or a high arched palate. There is no Argyll-Robertson pupil to suggest lewitic disease. To complete my examination, I would like to take patients BP looking for wide pulse pressure and severe hypertension. I would also want to look at the patients temperature chart. In summary, this patient has got AR that is severe with complication of CCF. Possible causes for this patients AR are Rh heart disease, infective endocarditis or congenital bicuspid valve. Questions What are the signs of severity of AR? S3 Austin Flint murmur (functional mdm at the apex due to regurgitant jet striking the anterior leaflet of the MV, therefore obstructing flow from the LA into the LV) Soft S2 Duration of the decrescendo murmur and loudness of murmur (cf with AS) Apex beat displaced and thrusting CCF Wide pulse pressure Hills sign

What are the characteristic signs of AR? Collapsing pulse Brachial dance Quinkes sign (visible capillary pulsation in the nail bed) Corrigans sign (Visible Carotid pulsation in the neck) De Mussets sign (head nodding in time with the heart beat Mullers sign (pulsation of the uvula) Traubes sign(pistol shots) and Duroziez sign(to and fro murmur on sl compression of the femoral artery) What are the causes of a collapsing pulse? AR PDA An aortopulmonary window A ruptured aneurysm of the aortic sinus Active Pagets High fever Severe Anaemia Pregnancy What would you expect to find on taking this patients blood pressure? Wide pulse pressure Severe hypertension (with functional AR) UL and LL discrepancy with systolic in LL>UL = Hills sign How do you differentiate an Austin Flint murmur from mitral stenosis? Opening snap Loud S1 Tapping apex beat, which is not displaced What are the causes of AR? Valvular Rh, IE and congenital biscupid valve (associated with CoA) Aortic root dilatation Syphilis, RA, AS, Marfan, severe hypertension Acute causes IE, trauma, Aortic dissection, rupture of sinus of valsalva How would you investigate? ECG LVH with diastolic overload pattern deep but narrow Q, isoelectric ST, and tall T waves in left praecordial leads CXR valvular calcification, cardiomegaly, pulmonary congestion, widened aorta 2D echo Confirm Dx Assess cause Severity

Complications

How would you manage this patient? Education Medical Antibiotic prophylaxis Treat underlying cause Treat complications such as CCF, IE Vasodilators ACE and CCB Surgical Indications Symptomatic CCF, angina and severe AR LV ESD >55mm Aortic root >55mm Reduction of EF >5% on exercise Types of surgery What is the prognosis? 4% develop symptoms, CCF or both annually