Let us take a look. Aortic regurg. Abnormality
of backward flow.
When is your aortic valve supposed to close?
Are you having problems with closing or opening?
Aortic stenosis, close your eyes, was it difficult
to it, aortic valve, opening right. That was
a systolic type of murmur whereas with aortic
regurg you have a problem with the aortic
valve closing. Which way does it close? Here my aorta, here
is my left ventricle, it is supposed to close this way
but it is not. It does not want to close
so therefore, there is going to be regurg.
When is it supposed to close? During diastole.
So what kind of murmur is aortic regurg? A diastolic
murmur. Your next question is well, is it early
or mid? I will
show you a picture where you will clearly see why
it is an early diastolic murmur.
Results from valve leaflets issues, aortic
root such as congestive heart failure or marfan,
what happens in marfan. It is the fibrilin
type of issue you are referring to chromosome
15 FFF, our elastic tissue is not being formed
properly and so, therefore, there might be
widening of the aortic root, welcome to aortic
regurg, congestive heart failure, Ehlers-Danlos, widening
of the aortic root. Could it be some type of
infection? Well what if you had a patient who
was in the armed forces and was away from
home for a long period of time and this patient
had urges and didn’t exactly use proper
judgment and comes back with issues with aortic
regurg. You have heard of syphilitic aortitis
haven’t you? Syphilitic aortitis, what happens?
There is something called arteritis obliterans. You have
talked about all these in microbiology. Just put
it together here and please understand that
the number of differentials that you have
with aortic regurg. Causes, talked about this
with aortic stenosis.
Dr. Raj, why is rheumatic heart disease here
with aortic regurg? Do you remember me telling
you first and foremost developing ,countries
is what you are looking at with rheumatic
heart disease, number 1. Number 2, we talked about the
organism being something like streptococci
pyogenes, Group A streptococci also referred
to something like pharyngitis in which the patient, the child,
perhaps wasn’t properly, inadequately treated resulting
in two to four weeks later issues with the
heart. We talked about all that.
Next, Early on you are going to cause damage
to the valve. You tell me, what valves predominantly
are going to be affected in rheumatic heart
disease? Left side, 95 percent of the time
and so you pay attention to that. Is that
clear? On the left side, early on what kind
of damage is it? It is regurg, it gets floppy,
vegetations. At some point, you begin the
repair process. What does repair meant to
you? Talk about fibrosis. Some may result
in stenosis and hence in aortic stenosis we
also had rheumatic heart disease but it's a
chronic type. Developing countries. And in
developed countries, what are you looking at? Interesting now,
we'll slow down here, look at me, pay attention. If it is a bicuspid
aortic valve first off you know it's a young patient.
The fact that you even have bicuspid is
a congenital issue, the last time we talked about
this was in a previous discussion of aortic
stenosis when we said that by having bicuspid
that you might have damaged tissue resulting
in dystrophic calcification and
what does that result in? That was aortic
stenosis, absolutely correct. So, in developed
countries, in which a patient who is young may
result in aortic regurg at some point, aortic
stenosis bicuspid may also result in regurg, is that clear?
And do not miss this question. This is where
students tend to get confused because they
are so black and white. You know certain things you
absolutely have to keep separate but at the
same time understand the continuum. You don’t
want to be so black and white that you miss
a question because "Oh, it has to be this." No, it
doesn’t have to be anything. The process
is important, so even bicuspid congenital
aortic valve may have aortic stenosis, what
kind of murmur was that? A crescendo-decrescendo. A systolic murmur,
or it could be a diastolic murmur. Where would you hear this early
diastolic murmur, please? Left parasternal moving towards
apex, maybe perhaps your third intercostal space. I hope that's clear.
You spend little bit of time with this paragraph. Let's move on.
What else may happen? It might cause damage due to infectious
endocarditis, marfan syndrome, trauma maybe
perhaps even aortic dissection. With aortic
dissection, imagine what may happen? You might
have stabbing back pain and when you have
stabbing back pain, if you have enough dissection
is it possible that you might then have retrograde
flow through the aortic root and cause widening and
expansion of the aortic root? Of course and
so your aortic regurg may be present and may be
even perhaps the blood is rushing in a very
rapid manner into the pericardial cavity.
What is that called, rushing rapidly? Tamponade.
A lot of things we are putting together because
it is not just bullet points in which you are
memorising. You are bringing in information in
which you are setting the foundation and building.
Aortic regurg has developed, then you have
more blood coming in, what is the ventricle
going to do? It will then cause increased
size hypertrophy resulting in what is known
as eccentric hypertrophy. Just like we have