Aortic Regurgitation

Explanation

An early diastolic decrescendo murmur at the left sternal edge that is accentuated by sitting forward in held expiration is the classic auscultatory signature of aortic regurgitation, a manoeuvre that brings the aortic root closer to the chest wall and removes the interposed lung. The wide pulse pressure of 148/52 mm Hg and the collapsing or water-hammer pulse arise because regurgitant flow back into the left ventricle during diastole causes a rapid fall in aortic diastolic pressure, while the augmented stroke volume raises the systolic pressure. Chronic volume overload produces eccentric left ventricular hypertrophy and dilatation, which explains the laterally displaced hyperdynamic apex. The patient's tall stature, long limbs, and joint hypermobility suggest Marfan syndrome, in which aortic root dilatation is the usual mechanism of regurgitation in young adults; other causes include bicuspid aortic valve, rheumatic disease, infective endocarditis, and aortic dissection. Aortic stenosis produces an ejection systolic murmur radiating to the carotids with a slow-rising, low-volume pulse and a narrow pulse pressure, the opposite haemodynamic picture. Mitral regurgitation gives a pansystolic murmur at the apex radiating to the axilla and is not diastolic. Tricuspid regurgitation gives a pansystolic murmur at the left lower sternal edge that increases on inspiration, with giant v waves in the jugular venous pulse and a pulsatile liver. Transthoracic echocardiography quantifies severity and root dimensions, and surgery is indicated for symptoms, for a left ventricular ejection fraction of 55% or less, or for progressive left ventricular dilatation.

Why each option

A.

Aortic stenosis produces an ejection systolic murmur radiating to the carotids with a slow-rising pulse and narrow pulse pressure.

B.

Correct. An early diastolic murmur at the left sternal edge accentuated by leaning forward in expiration, with a wide pulse pressure and collapsing pulse, defines aortic regurgitation.

C.

Mitral regurgitation gives a pansystolic apical murmur radiating to the axilla, not a diastolic murmur at the base.

D.

Tricuspid regurgitation gives a pansystolic murmur that increases on inspiration, with giant v waves and a pulsatile liver.

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