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Encyclopedia > De Musset's sign
Aortic insufficiency
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ICD-10 I06, I35, Q23
ICD-9 395.1, 746.4
ICD-O: {{{ICDO}}}
OMIM {{{OMIM}}}
DiseasesDB {{{DiseasesDB}}}
MedlinePlus {{{MedlinePlus}}}
eMedicine {{{eMedicineSubj}}}/{{{eMedicineTopic}}}
MeSH {{{MeshNumber}}}

Aortic insufficiency (AI), also known as aortic regurgitation (AR), is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle. The following codes are used with International Statistical Classification of Diseases and Related Health Problems. ... The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. ... The International Classification of Diseases for Oncology (ICD-O) is a domain specific extension of the International Statistical Classification of Diseases and Related Health Problems for tumor diseases. ... The Mendelian Inheritance in Man project is a database that catalogues all the known diseases with a genetic component, and - when possible - links them to the relevant genes in the human genome. ... The Diseases Database is a free website that provides information about the relationships between medical conditions, symptoms, and medications. ... MedlinePlus (medlineplus. ... eMedicine is an online clinical medical knowledge base that was founded in 1996. ... Medical Subject Headings (MeSH) is a huge controlled vocabulary (or metadata system) for the purpose of indexing journal articles and books in the life sciences. ... The aortic valve is one of the valves of the heart. ... The heart and lungs, from an older edition of Grays Anatomy. ... Diastole is the period of time when the heart relaxes after contraction. ... The largest artery in the human body, the aorta originates from the left ventricle of the heart and brings oxygenated blood to all parts of the body in the systemic circulation. ... In the heart, a ventricle is a chamber which collects blood from an atrium (another heart chamber) and pumps it out of the heart. ...


Aortic insufficiency can be due to abnormalities of either the aortic valve or the aortic root (the beginning of the aorta). The largest artery in the human body, the aorta originates from the left ventricle of the heart and brings oxygenated blood to all parts of the body in the systemic circulation. ...

Contents


Etiology

About half of the cases of aortic insufficiency are due to the aortic root dilatation (annuloaortic ectasia), which is idiopathic in over 80% of cases, but otherwise occurs with aging and hypertension, Marfan syndrome, aortic dissection, and syphilis. In about 15% the cause is innate bicuspidal aortic valve, while another 15% cases are due to retraction of the cusps as part of postinflammatory processes of endocarditis in rheumatic fever and various collagen vascular diseases. Idiopathic is a medical adjective that indicates that a recognized cause has not yet been established. ... In biology, senescence is the combination of processes of deterioration which follow the period of development of an organism. ... For other forms of hypertension see hypertension (disambiguation) Hypertension or high blood pressure is a medical condition wherein the blood pressure is chronically elevated. ... Marfan syndrome is a connective tissue disorder characterized by unusually long limbs. ... Aortic dissection is a tear in the wall of the aorta (the largest artery of the body). ... Syphilis (historically called lues) is a sexually transmitted disease (STD) that is caused by a spirochaete bacterium, Treponema pallidum. ... Endocarditis is an inflammation of the inner layer of the heart, the endocardium. ... Rheumatic fever is an inflammatory disease which may develop after a Group A streptococcal infection (such as strep throat or scarlet fever) and can involve the heart, joints, skin, and brain. ...


Physiology

In individuals with a normally functioning aortic valve, the valve is only open when the pressure in the left ventricle is higher than the pressure in the aorta. This allows the blood to be ejected from the left ventricle into the aorta during ventricular systole. After ventricular systole, the pressure in the ventricle decreases, as the ventricle relaxes and gets ready to fill up with blood from the left atrium. This relaxation of the left ventricle (early ventricular diastole) causes a fall in the pressure in the left ventricle. When the pressure in the left ventricle falls below the pressure in the aorta, the aortic valve will close, preventing blood from going from the aorta back into the left ventricle. The amount of blood that is ejected by the heart is known as the stroke volume or stroke work. Under normal conditions, the entire stroke volume delivers oxygenated blood to the body. In the heart, a ventricle is a chamber which collects blood from an atrium (another heart chamber) and pumps it out of the heart. ... The largest artery in the human body, the aorta originates from the left ventricle of the heart and brings oxygenated blood to all parts of the body in the systemic circulation. ... Systole can mean the following: Systole (medicine) is a term describing the contraction of the heart. ... This page is about the muscular organ, the Heart. ... Diastole is the period of time when the heart relaxes after contraction. ... The largest artery in the human body, the aorta originates from the left ventricle of the heart and brings oxygenated blood to all parts of the body in the systemic circulation. ... The aortic valve is one of the valves of the heart. ...


Pathophysiology

In aortic insufficiency, when the pressure in the left ventricle falls below the pressure in the aorta, the aortic valve is not able to completely close. This causes a leaking of blood from the aorta into the left ventricle. This means that some of the blood that was already ejected from the heart is regurgitating back into the heart. The percentage of blood that regurgitates back through the aortic valve due to AI is known as the regurgitant fraction. For instance, if an individual with AI has a stroke volume of 100 ml and during ventricular diastole 25 ml regurgitates back through the aortic valve, the regurgitant fraction is 25%. This regurgitant flow causes a decrease in the diastolic blood pressure, and therefore an increase in the pulse pressure (systolic pressure - diastolic pressure) and hypertension. The millilitre (ml or mL, also spelt milliliter) is a metric unit of volume that is equal to one thousandth of a litre. ... Diastole is the period of time when the heart relaxes after contraction. ... The millilitre (ml or mL, also spelt milliliter) is a metric unit of volume that is equal to one thousandth of a litre. ... Diastolic is the adjective form of diastole referring to relaxation of the heart, between muscle contractions. ... For other forms of hypertension see hypertension (disambiguation) Hypertension or high blood pressure is a medical condition wherein the blood pressure is chronically elevated. ...


Since some of the blood that is ejected during systole regurgitates back during diastole, there is decreased effective forward flow in AI. Systole can mean the following: Systole (medicine) is a term describing the contraction of the heart. ... Diastole is the period of time when the heart relaxes after contraction. ...


AI causes both volume overload (elevated preload) and pressure overload (elevated afterload) of the heart. In cardiac physiology, preload is the volume of blood present in a ventricle of the heart, after passive filling and atrial contraction. ... In cardiac physiology, afterload is the tension produced by a chamber of the heart in order to contract. ...


The pressure overload (due to elevated pulse pressure and hypertension) causes left ventricular hypertrophy (LVH). There is both concentric hypertrophy and eccentric hypertrophy in AI. The concentric hypertrophy is due to the hypertension associated with AI, while the eccentric hypertrophy is due to volume overload caused by the regurgitant fraction. Left ventricular hypertrophy (LVH) is the abnormal thickening of the myocardium (muscle) of the left ventricle of the heart. ...


Hemodynamics

The hemodynamic sequelae of AI are dependent on the rate of onset of AI. Acute AI and chronic AI will have different hemodynamics and individuals will have different signs and symptoms.


Acute aortic insufficiency

In acute AI, as may be seen with acute perforation of the aortic valve due to endocarditis, there will be a sudden increase in the volume of blood in the left ventricle. The ventricle, unable to deal with the sudden change in volume, and will decompensate. The filling pressure of the left ventricle will increase. This causes pressure in the left atrium to rise, and the individual will develop congestive heart failure. Endocarditis is an inflammation of the inner layer of the heart, the endocardium. ... In the heart, a ventricle is a chamber which collects blood from an atrium (another heart chamber) and pumps it out of the heart. ... This page is about the muscular organ, the Heart. ... Congestive heart failure (CHF), also called congestive cardiac failure (CCF) or just heart failure, is the inability of the heart to pump a sufficient amount of blood throughout the body, or requiring elevated filling pressures in order to pump effectively. ...


Severe acute aortic insufficiency is considered a medical emergency. There is a high mortality rate if the individual does not undergo immediate surgery for aortic valve replacement. If the acute AI is due to aortic valve endocarditis, there is a risk that the new valve may become seeded with bacteria. However, this risk is small.1 The aortic valve is one of the valves of the heart. ...


Acute AI may be difficult to diagnose clinically, since the left ventricle had not yet developed the eccentric hypertrophy and dilatation that allow an increased stroke volume and bounding peripheral pulses that are common in chronic AI. On auscultation, there may be a short diastolic murmur and a soft S1. S1 is soft because the elevated filling pressures close the mitral valve in diastole (rather than the mitral valve being closed at the beginning of systole). The heart sounds are the noises (sound) generated by the beating heart and the resultant flow of blood through it. ... Diastole is the period of time when the heart relaxes after contraction. ... Diastole is the period of time when the heart relaxes after contraction. ... Systole can mean the following: Systole (medicine) is a term describing the contraction of the heart. ...


Chronic aortic insufficiency

If the individual survives the initial hemodynamic derailment that acute AI presents as, the left ventricle adapts by eccentric hypertrophy and dilatation of the left ventricle, and the volume overload is compensated for. The left ventricular filling pressures will revert to normal and the individual will no longer have overt heart failure. Left ventricular hypertrophy (LVH) is the abnormal thickening of the myocardium (muscle) of the left ventricle of the heart. ... The term dilation may have a number of meanings: In physiology, where it is synonymous with dilatation, it may mean: Pupil dilation (mydriasis) Dilation of blood vessels (vasodilation) Cervical dilation (or dilation of the cervix) in childbirth Dilation and curettage (surgical dilation) Dilation following vaginoplasty In mathematics: Dilation In [[physics...


In this compensated phase, the individual may be totally asymptomatic and may have normal exercise tolerance.


Eventually (typically after a latency period) the left ventricle will become decompensated, and filling pressures will increase. While most individuals would complain of symptoms of congestive heart failure to their physicians, some enter this decompensated phase asymptomatically. Proper treatment for AI involves aortic valve replacement prior to this decompensation phase. The aortic valve is one of the valves of the heart. ...


Physical examination

The physical examination of an individual with aortic insufficiency involves auscultation of the heart to listen for the murmur of aortic insufficiency and related heart sounds. The murmur of chronic aortic insufficiency is a holodiastolic (lasts all of diastole) decrescendo murmur (starts off loud and becomes soft). The murmur of chronic aortic insufficiency has the following characteristics: In medicine, the physical examination or clinical examination is the process by which the physician investigates the body of a patient for signs of disease. ... Auscultation is the technical term for listening to the internal sounds of the body, usually using a stethoscope. ... The heart sounds are the noises (sound) generated by the beating heart and the resultant flow of blood through it. ... Diastole is the period of time when the heart relaxes after contraction. ...

  • Systolic ejection click
  • Ejection murmur
  • S3 present
  • Holodiastolic decrescendo murmur - best heard with patient sitting and leaning forward (If radiation to the right parasternal region, consider ascending aortic aneurysm)
  • Austin flint murmur (an apical diastolic rumble due to mitral regurgitation)

Physical signs of aortic insufficiency are related to the high pulse pressure and the rapid decrease in blood pressure during diastole due to the AI:

  • Lighthouse sign (blanching & flushing of forehead)
  • de Musset's sign (head nodding in time with the heart beat)
  • Ladolfi's sign (alternating constriction & dilatation of pupil)
  • Becker's sign (pulsations of retinal vessels)
  • Muller's sign (pulsations of uvula)
  • Corrigan's pulse (rapid upstroke and collapse of the carotid artery pulse)
  • (Watson's) Water-hammer pulse
  • Quincke's sign (pulsation of the capillary bed in the nail)
  • Mayen's sign (diastolic drop of BP>15 mm Hg with arm raised)
  • Rosenbach's sign (pulsatile liver)
  • Gerhardt's sign (enlarged spleen)
  • Duroziez's sign (systolic and diastolic murmurs heard over the femoral artery when it is gradually compressed)
  • Hill's sign (A ≥ 20 mmHg difference in popliteal and brachial systolic cuff pressures, seen in chronic severe AI)
  • Traube's sign (a double sound heard over the femoral artery when it is compressed distally)
  • Lincoln sign (pulsatile popliteal)
  • Sherman sign (dorsalis pedis pulse is quickly located & unexpectedly prominent in age>75 yr)

In human anatomy, the carotid artery is a major artery of the head and neck. ...

Diagnostic evaluation

The most common test used for the evaluation of the severity of aortic insufficiency is the echocardiogram, which can provide two-dimensional views of the regurgitant jet, and allow measurement of the velocity and volume of the jet. The echocardiogram is an ultrasound of the heart. ...


The echocardiographic findings in severe aortic regurgitation include:

  • An AI color jet dimension > 60 percent of the left ventricular outflow tract (LVOT) diameter (may not be true if the jet is eccentric)
  • The pressure half-time of the regurgitant jet is < 250 msec
  • Early termination of the mitral inflow (due to increase in LV pressure due to the AI.)
  • Early diastolic flow reversal in the descending aorta.
  • Regurgitant volume > 60 ml
  • Regurgitant fraction > 55 percent

Mil-li-sec-ond One hundreth of a second ... The millilitre (ml or mL, also spelt milliliter) is a metric unit of volume that is equal to one thousandth of a litre. ...

Prognosis

The risk of death in individuals with aortic insufficiency, dilated ventricle, normal ejection fraction who are asymptomatic is about 0.2 percent per year. Risk increases if the ejection fraction decreases or if the individual develops symptoms. The ejection fraction (EF) or, more correctly, left-ventricular ejection fraction (often abbreviated LVEF) is a measure of how much blood the left ventricle of the heart pumps out with each contraction. ...


Treatment

Indications for surgery for chronic severe aortic insufficiency2
Symptoms Ejection fraction Other information
NYHA class III - IV ≥ 50 %
NYHA class II ≥ 50 % Progression of symptoms or worsoning parameters on echocardiography
CHA class ≥ II angina ≥ 50 %
Regardless of symptoms 25 - 49 %
Cardiac surgery for other cause (ie: CAD, other valvular disease, ascending aortic aneurysm)

Aortic insufficiency can be treated either medically or surgically, depending on the acuteness of presentation, the symptoms and signs associated with the disease process, and the degree of left ventricular dysfunction. The New York Heart Association (NYHA) Functional Classification provides a simple way of classifying the extent of heart failure. ... angina tonsillaris see tonsillitis. ... Coronary heart disease (CHD), also called coronary artery disease (CAD) and atherosclerotic heart disease, is the end result of the accumulation of atheromatous plaques within the walls of the arteries that supply the myocardium (the muscle of the heart). ...


Surgical treatment is typically warranted prior to the ejection fraction falling below 55% or the left ventricular end-systolic dimension falling below 55mm, regardless of symptoms. If either of these thresholds is passed, the prognosis worsens. The ejection fraction (EF) or, more correctly, left-ventricular ejection fraction (often abbreviated LVEF) is a measure of how much blood the left ventricle of the heart pumps out with each contraction. ... A millimetre (American spelling: millimeter), symbol mm is an SI unit of length that is equal to one thousandth of a metre. ...


Medical treatment

Medical therapy of chronic aortic insufficiency involves the use of vasodilators. Small trials have shown a short term benefit in the use of ACE inhibitors, nifedipine, and hydralazine in improving left ventricular wall stress, ejection fraction, and mass. The use of these vasodilators is only indicated in individuals who suffer from hypertension in addition to AI. The goal in using the use of these pharmacologic agents is to decrease the afterload so that the left ventricle is spared somewhat. The regurgitant fraction may not change significantly, since the gradient between the aortic and left ventricular pressures is usually fairly low at the initiation of treatment. ACE inhibitors, or inhibitors of Angiotensin-Converting Enzyme, are a group of pharmaceuticals that are used primarily in treatment of hypertension and congestive heart failure, in most cases as the drugs of first choice. ... Nifedipine is a dihydropyridine calcium channel blocker. ... Hydralazine hydrochloride (1 -hydrazinophthalazine monohydrochloride; Apresoline®) is a medication used to treat high blood pressure. ... For other forms of hypertension see hypertension (disambiguation) Hypertension or high blood pressure is a medical condition wherein the blood pressure is chronically elevated. ... In cardiac physiology, afterload is the tension produced by a chamber of the heart in order to contract. ...


Surgical treatment

The surgical treatment of choice at this time is an aortic valve replacement. This is currently an open-heart procedure, requiring the individual to be placed on circulatory arrest. The aortic valve is one of the valves of the heart. ...


In the case of severe acute aortic insufficiency, all individuals should undergo surgery if there are no absolute contraindications for surgery. Individuals with bacteremia with aortic valve endocarditis should not wait for treatment with antibiotics to take effect, given the high mortality associated with the acute AI. In stead, replacement with an aortic valve homograft should be performed if feasible. It has been suggested that this article or section be merged with Heart valve prosthesis. ...


In the future, it is believed that a percutaneous approach to aortic valve replacement will be feasible. In surgery, percutaneous pertains to any medical procedure where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using an open approach where inner organs or tissue are exposed (typically with the use of a scalpel). ...


References

1. al Jubair K, al Fagih MR, Ashmeg A, Belhaj M, Sawyer W. Cardiac operations during active endocarditis. J Thorac Cardiovasc Surg. 1992 Aug;104(2):487-90. (Medline abstract)


2. Bonow et al., ACC/AHA Task Force Report. ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease. JACC Vol. 32, No. 5, November 1998:1486-1588 (Full article)


See also


 
 

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