Percussion and physical examination
During physical examination, the apex beat may be hyperdynamic, displaced to the left, and inferiorly. Chest percussion reveals a specific "aortic configuration" of the heart. The borders of cardiac dullness are significantly expanded downward and to the left, reflecting progressive left ventricular hypertrophy and dilation. In the early stages of the defect, the cardiac "waist" is accentuated, giving the heart silhouette a characteristic boot-like or duck-like shape. Although physical examination findings are mostly supportive, they guide further instrumental investigations.
Heart and vessel auscultation
Auscultation is a crucial stage of diagnosis. The main sign of the defect is a high-pitched, soft, decrescendo (decrescendo) diastolic murmur. It results from the backflow of blood (regurgitation) from the aorta. The murmur is localized in the 2nd intercostal space to the right of the sternum and at Botkin-Erb's point, where its maximum is often determined. It is best heard when the patient sits leaning forward and takes a deep expiration.
Changes in heart sounds and additional murmurs:
- The second sound ($S_2$) over the aorta is usually diminished due to cusp defect.
- Sometimes immediately after the first sound ($S_1$), a pathological opening sound (ejection sound) can be heard.
- A systolic murmur over the aorta is frequently recorded, caused by a massive stroke volume passing through the valve, creating relative stenosis.
- Flint murmur (Austin Flint) — a presystolic murmur at the apex. The regurgitant jet strikes the anterior leaflet of the mitral valve, pushing it back and obstructing blood flow from the atrium.
Vascular phenomena may be auscultated over large vessels, such as the femoral artery, for instance, Traube's double sound — loud "cannon" sounds in systole and diastole caused by sharp blood pressure fluctuations.
Instrumental diagnostics
The definitive diagnosis is confirmed using imaging and functional modalities:
- Echocardiography (EchoCG): The key method. The screen shows wall thickening and left ventricular cavity dilation, as well as hyperdynamic systolic pulsation. Doppler mode reliably confirms the defect by recording retrograde blood flow in diastole.
- Electrocardiography (ECG): Against the background of sinus rhythm, signs of left ventricular overload are recorded: tall R waves, ST-segment depression, and negative T waves in left chest leads ($V_5, V_6$).
- Radiography: Shows an widened aortic shadow with hyperdynamic pulsation and aortic configuration. In late stages, with the so-called "mitralization" of the defect, the left atrium may enlarge, smoothing out the cardiac "waist".
- Invasive methods: Angiocardiography and catheterization are used in complex cases when non-invasive data are insufficient.
Principles of treatment
Patient management tactics depend on the etiology of the defect and the severity of hemodynamic impairment.
- Etiotropic therapy: Treatment of the underlying disease is paramount. This is critically important, for example, in infective endocarditis, where intensive antibiotic support is required.
- Symptomatic treatment: Aims to manage the manifestations of heart failure and is carried out according to approved therapeutic protocols.
- Surgical treatment: Indicated when regurgitation is due to severe damage or dilation of the aorta itself, requiring valve or vascular replacement.
Briefly: answers to topical questions
What peripheral vascular signs are characteristic of aortic regurgitation?
Severe aortic regurgitation is characterized by numerous peripheral vascular signs caused by sharp pressure drops and hyperdynamic pulsation.
- Corrigan's sign — visible pulsation of the common carotid arteries (" carotid dance").
- Quincke's sign — nail bed pulsation (pseudocapillary pulse).
- Musset's sign — rhythmic nodding of the head synchronous with the pulse.
- Mueller's sign — pulsation of the uvula.
- Landolfi's sign — pupillary pulsation (constriction and dilation).
- Water-hammer pulse (pulsus celer et altus) — a collapsing, bounding pulse with a rapid upstroke and downstroke.
- Traube's double sound and Duroziez's double murmur — auscultated over the femoral arteries.
What diseases are the main causes of acquired aortic regurgitation?
The main causes of aortic regurgitation are divided into two groups: primary valve cusp pathology and aortic root/wall pathology.
- Valve cusp pathology: rheumatic fever (the most frequent cause), infective endocarditis, sclerotic degeneration.
- Aortic root or wall pathology: syphilis/syphilitic aortitis, aortic dissection, Marfan syndrome/connective tissue dysplasia, arterial hypertension, inflammatory diseases (ankylosing spondylitis, aortitis).
To understand the mechanism of the Flint murmur (Austin Flint), imagine that the regurgitant jet from the aorta is a draft that closes a door (the anterior mitral leaflet), hindering normal blood flow from the atrium to the ventricle.
Class and exam questions
Why is the pulse pressure so wide in aortic regurgitation?
In systole, the left ventricle ejects a massive volume of blood, sharply raising systolic pressure. In diastole, a significant portion of this blood leaks back into the heart, causing diastolic pressure to drop precipitously, sometimes to zero.
Where is Botkin-Erb's point located?
It is located in the third intercostal space to the left of the sternum. This is the optimal auscultation site for diastolic murmurs originating from the aorta.
What does the term "mitralization of a heart defect" mean?
This is a late stage of the disease where the left ventricle dilates so much that the mitral valve ring widens. Relative mitral regurgitation develops, the left atrium enlarges, and the aortic "waist" disappears on radiography.
What else to study on this topic
- Mechanisms of Traube's double sound and other vascular phenomena.
- Differential diagnosis of organic and relative systolic murmurs on the aorta.
- Specifics of ECG criteria in left ventricular hypertrophy and dilation.
- Indications for angiocardiography and invasive catheterization in heart defects.
- Features of conservative management of heart failure in aortic regurgitation.
Master the entire topic in the "Propaedeutics" course
This is a summary. The course covers everything tested in classes and exams.
- Complete study guide on "Aortic Regurgitation: Diagnosis and Treatment" and 3,152 more pages of this subject
- Assignments and quizzes after every topic — just like in a colloquium
- AI tutor answers questions on the topic anytime
- 113 video lessons on the subject
Other topics in the "Cardiovascular system" section
Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.