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 International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) is a coding of diseases and signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or diseases, as classified by the World Health Organization (WHO). ... // I00-I99 - Diseases of the circulatory system (I00-I02) Acute rheumatic fever (I00) Rheumatic fever without mention of heart involvement (I01) Rheumatic fever with heart involvement (I02) Rheumatic chorea (I05-I09) Chronic rheumatic heart diseases (I05) Rheumatic mitral valve diseases (I050) Mitral stenosis (I051) Rheumatic mitral insufficiency (I06) Rheumatic aortic... // I00-I99 - Diseases of the circulatory system (I00-I02) Acute rheumatic fever (I00) Rheumatic fever without mention of heart involvement (I01) Rheumatic fever with heart involvement (I02) Rheumatic chorea (I05-I09) Chronic rheumatic heart diseases (I05) Rheumatic mitral valve diseases (I050) Mitral stenosis (I051) Rheumatic mitral insufficiency (I06) Rheumatic aortic... // Q00-Q99 - Congenital malformations, deformations and chromosomal abnormalities (Q00-Q07) Congenital malformations of the nervous system (Q00) Anencephaly and similar malformations (Q01) Encephalocele (Q02) Microcephaly (Q03) Congenital hydrocephalus (Q04) Other congenital malformations of brain (Q05) Spina bifida (Q06) Other congenital malformations of spinal cord (Q07) Other congenital malformations of nervous... The International Statistical Classification of Diseases and Related Health Problems (most commonly known by the abbreviation ICD) provides codes to classify diseases and a wide variety of signs, symptoms, abnormal findings, complaints, social circumstances and external causes of injury or disease. ... The following is a list of codes for International Statistical Classification of Diseases and Related Health Problems. ... The Disease Bold textDatabase is a free website that provides information about the relationships between medical conditions, symptoms, and medications. ... 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 aorta (generally pronounced [eɪˈɔːtə] or ay-orta) is the largest artery in the human body, originating from the left ventricle of the heart and bringing 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 aorta (generally pronounced [eɪˈɔːtə] or ay-orta) is the largest artery in the human body, originating from the left ventricle of the heart and bringing oxygenated blood to all parts of the body in the systemic circulation. ...

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. Additionally, aortic insufficiency has been linked to the use of some medications belonging to the class of serotonin reuptake inhibitors, specifically medications containing fenfluramine or dexfenfluramine isotopes,^[1][2] and dopamine agonists.^[3][4] Idiopathic means arising spontaneously or from an obscure or unknown cause. ... 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). ... Marfan syndrome is an autosomal dominant genetic disorder of the connective tissue characterized by disproportionately long limbs, long thin fingers, a typically tall stature, and a predisposition to cardiovascular abnormalities, specifically those affecting the heart valves and aorta. ... Aortic dissection is a tear in the wall of the aorta (the largest artery of the body). ... Syphilis is a curable sexually transmitted disease caused by the Treponema pallidum spirochete. ... 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. ... A connective tissue disease is any disease that has the connective tissues of the body as a primary target of pathology. ... Fenfluramine is a drug that was part of the Fen-Phen anti-obesity medication (the other drug being phentermine). ... Dexfenfluramine, also marketed under the name Redux, is a appetite-suppresant drug. ... A dopamine agonist is a compound that activates dopamine receptors, mimicking the effect of the neurotransmitter dopamine. ...

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 aorta (generally pronounced [eɪˈɔːtə] or ay-orta) is the largest artery in the human body, originating from the left ventricle of the heart and bringing 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. ... Anterior (frontal) view of the opened heart. ... Diastole is the period of time when the heart relaxes after contraction. ... The aorta (generally pronounced [eɪˈɔːtə] or ay-orta) is the largest artery in the human body, originating from the left ventricle of the heart and bringing oxygenated blood to all parts of the body in the systemic circulation. ... The aortic valve is one of the valves of the heart. ... In cardiovascular physiology, ejection fraction (Ef) is the fraction of blood pumped out of a ventricle with each heart beat. ... In cardiovascular physiology, stroke volume (SV) is the volume of blood ejected from a ventricle with each beat 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 in the aorta, and therefore an increase in the pulse pressure (systolic pressure - diastolic pressure). 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. ... Pulse pressure is the change in blood pressure seen during a contraction of the heart. ...

Since some of the blood that is ejected during systole regurgitates back into the left ventricle 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. ...

Note that while diastolic blood pressure is diminished and the pulse pressure widens, systolic blood pressure generally remains normal or can even be slightly elevated. This is due to the fact that sympathetic nervous system and the renin-angiotensin-aldosterone axis of the kidneys compensate for the decreased cardiac output. Catecholamines will increase the heart rate and increase the strength of ventricular contraction, directly increasing cardiac output. Catecholamines will also cause peripheral vasoconstriction, which causes increased systemic vascular resistance and ensures that core organs are adequately perfused. Renin, a proteolytic enzyme, cleaves angiotensinogen to angiotensin I, which is converted to angiotensin II, which is also a potent vasoconstrictor. In the case of chronic aortic insufficiency with resultant cardiac remodeling, heart failure will develop, and it is possible to see systolic pressures diminish. Catecholamines are chemical compounds derived from the amino acid tyrosine that act as hormones or neurotransmitters. ... Not to be confused with rennin, the active enzyme in rennet. ... Angiotensinogen, angiotensin I and angiotensin II are peptides involved in maintenance of blood volume and pressure. ... Angiotensin is an oligopeptide in the blood that causes vasoconstriction, increased blood pressure, and release of aldosterone from the adrenal cortex. ... Angiotensin is an oligopeptide in the blood that causes vasoconstriction, increased blood pressure, and release of aldosterone from the adrenal cortex. ...

AI causes both volume overload (elevated preload) and pressure overload (elevated afterload) of the heart. Heart during ventricular diastole. ... 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 the systemic effects of neuroendocrine hormones) causes left ventricular hypertrophy (LVH). There is both concentric hypertrophy and eccentric hypertrophy in AI. The concentric hypertrophy is due to the increased left ventricular systolic pressures associated with AI, while the eccentric hypertrophy is due to volume overload caused by the regurgitant fraction. Left ventricular hypertrophy (LVH) is the 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. Hemodynamics is concerned with the forces generated by the heart and the motion of blood through the cardiovascular system. ...

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 is unable to deal with the sudden change in volume. In terms of the Frank-Starling curve, the end-diastolic volume will be very high, such that further increases in volume result in less and less efficient contraction. The filling pressure of the left ventricle will increase. This causes pressure in the left atrium to rise, and the individual will develop pulmonary edema. 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. ... Anterior (frontal) view of the opened heart. ... Pulmonary edema is swelling and/or fluid accumulation in the lungs. ...

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.^[5] {{Otheruses4|the medical term|the Australian television series|Medical Emergenc an immediate threat to a persons life or long term health. ... Aortic valve replacement is a cardiac surgery procedure in which a patients aortic valve is replaced by a different valve. ... Endocarditis is an inflammation of the inner layer of the heart, the endocardium. ... Phyla Actinobacteria Aquificae Chlamydiae Bacteroidetes/Chlorobi Chloroflexi Chrysiogenetes Cyanobacteria Deferribacteres Deinococcus-Thermus Dictyoglomi Fibrobacteres/Acidobacteria Firmicutes Fusobacteria Gemmatimonadetes Lentisphaerae Nitrospirae Planctomycetes Proteobacteria Spirochaetes Thermodesulfobacteria Thermomicrobia Thermotogae Verrucomicrobia Bacteria (singular: bacterium) are unicellular microorganisms. ...

Acute AI usually presents as florid congestive heart failure, and will not have any of the signs associated with chronic AI since the left ventricle had not yet developed the eccentric hypertrophy and dilatation that allow an increased stroke volume, which in turn cause bounding peripheral pulses. 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). Congestive heart failure (CHF), also called congestive cardiac failure (CCF) or just heart failure, is a condition that can result from any structural or functional cardiac disorder that impairs the ability of the heart to fill with or pump a sufficient amount of blood throughout the body. ... Front of thorax, showing surface relations of bones, lungs (purple), pleura (blue), and heart (red outline). ... 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 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. Aortic valve replacement is a cardiac surgery procedure in which a patients aortic valve is replaced by a different valve. ...

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 the S4 heart sound (which would indicate left ventricular filling against a hypertrophied LV wall). The murmur of chronic aortic insufficiency is typically described as early diastolic and decresendo, which is best heard at aortic area when the patient is seated and leans forward with breath held in expiration. The murmur is usually soft and seldom causes thrill. If there is radiation to the right parasternal region, ascending aortic aneurysm has to be excluded. 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. ...

If there is increased stroke volume of the left ventricle due to volume overload, an ejection systolic 'flow' murmur may also be present when auscultating the same aortic area. Unless there is concomittant aortic valve stenosis, the murmur should not start with an ejection click. Aortic valve stenosis (AS) is a heart condition caused by the incomplete opening of the aortic valve. ...

There may also be an Austin Flint murmur, a soft mid-diastolic rumble heard at the apical area. It appears when regurgitant jet from the severe aortic insufficiency renders partial closure of the anterior mitral leaflet. In cardiology, an Austin Flint murmur is a mid-diastolic, low-pitched rumbling murmur which is best heard at the cardiac apex. ...

Peripheral 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, although usefulness of some of the eponymous signs has been questioned:^[6]

• large-volume, 'collapsing' pulse
• bounding peripheral pulses; also known as Watson's water hammer pulse
• low diastolic and increased pulse pressure
• Corrigan's pulse (rapid upstroke and collapse of the carotid artery pulse)
• de Musset's sign (head nodding in time with the heart beat)
• Quincke's sign (pulsation of the capillary bed in the nail)
• Traube's sign (systolic and diastolic murmurs described as 'pistol shots' heard over the femoral artery when it is gradually compressed)
• Duroziez's sign (a double sound heard over the femoral artery when it is compressed distally)

Rarer signs include: Watsons water hammer pulse is the medical sign which describes a pulse that is bounding and forceful, as if it were the hitting of a water hammer that was causing the pulse. ... Diastolic is the adjective form of diastole referring to relaxation of the heart, between muscle contractions. ... Watsons water hammer pulse is the medical sign which describes a pulse that is bounding and forceful, as if it were the hitting of a water hammer that was causing the pulse. ... In human anatomy, the carotid artery is a major artery of the head and neck. ... 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. ... 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. ...

• Lighthouse sign (blanching & flushing of forehead)
• Landolfi's sign (alternating constriction & dilatation of pupil)
• Becker's sign (pulsations of retinal vessels)
• Müller's sign (pulsations of uvula)
• Mayen's sign (diastolic drop of BP>15 mm Hg with arm raised)
• Rosenbach's sign (pulsatile liver)
• Gerhardt's sign (enlarged spleen)
• Hill's sign - a ≥ 20 mmHg difference in popliteal and brachial systolic cuff pressures, seen in chronic severe AI. Considered to be an artefact of sphygmomanometric lower limb pressure measurement.^[7]
• Lincoln sign (pulsatile popliteal)
• Sherman sign (dorsalis pedis pulse is quickly located & unexpectedly prominent in age>75 yr)

Unfortunately, none of the above putative signs of aortic insufficiency is of utility in making the diagnosis.^[8] What is of value is hearing a diastolic murmur itself, whether or not the above signs are present. Müllers sign is the pulsation or bobbing of the uvula that occurs during systole. ... 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. ...

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

One millisecond is one-thousandth 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. In cardiovascular physiology, ejection fraction (Ef) is the fraction of blood pumped out of a ventricle with each heart beat. ...

Treatment

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 controversial in asymptomatic patients, however has been recommended if the ejection fraction falls below 50% or in the face of progressive and severe left ventricular dilatation. For both groups of patients, surgery before the development of worse ejection fracture/LV systolic dilatation, is expected to reduce the risk of sudden death, and is associated with lower peri-operative mortality. In cardiovascular physiology, ejection fraction (Ef) is the fraction of blood pumped out of a ventricle with each heart beat. ...

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 these pharmacologic agents is to decrease the afterload so that the left ventricle is somewhat spared. 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. Captopril, the first ACE inhibitor 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 (brand name Adalat and Procardia) 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). ... 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 cardiopulmonary bypass. Aortic valve replacement is a cardiac surgery procedure in which a patients aortic valve is replaced by a different valve. ... A Heart-Lung Machine (upper right) in a Coronary Artery Bypass surgery (CABG) Cardiopulmonary bypass (CPB) is a technique that temporarily takes over the function of the heart and lungs during surgery. ...

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 hoped 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

A digital object identifier (or DOI) is a standard for persistently identifying a piece of intellectual property on a digital network and associating it with related data, the metadata, in a structured extensible way. ... A digital object identifier (or DOI) is a standard for persistently identifying a piece of intellectual property on a digital network and associating it with related data, the metadata, in a structured extensible way. ... A digital object identifier (or DOI) is a standard for persistently identifying a piece of intellectual property on a digital network and associating it with related data, the metadata, in a structured extensible way. ... A digital object identifier (or DOI) is a standard for persistently identifying a piece of intellectual property on a digital network and associating it with related data, the metadata, in a structured extensible way. ...

External links

• Heart Disease and Life After by Richard Hinkle

See also

• Aortic valve replacement
• Preload
• Afterload