Aortic Regurgitation: Visualization

by Carlo Raj, MD

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    00:01 Just like we have done with aortic stenosis. Once again here it is important that your physiology is solid.

    00:07 A couple of things here I am going to point out to you that without a doubt you should not be able to miss. Let's continue here. Let us begin at the first point. You see where it says diastolic blood pressure, so here we are comparing once again, our left ventricular pressure curve to the aortic pressure curve. I want you to notice right off the bat, is there any discrepancy between the left ventricular pressure curve and the aortic pressure curve on your left graph? No there isn’t. Because that should be in parallel meaning to say when the left ventricle is ejecting blood into the aorta, the pressure between the two chambers, left ventricle and the aorta should be synonymous, should be in parallel, should be in synchrony. And it is, even here. So that's not my issue, it is not aortic stenosis. You want to go back and take a look at aortic stenosis. There is a huge discrepancy between those two curves, here we don’t see that and so we know it is not aortic stenosis. Next, where is my issue, you tell me, when is the aortic valve supposed to close? EC versus S2, right underneath S2 is where that aortic valve is supposed to close. That is the beginning of diastole. Isn’t that? And that is when the aortic valve closes but it can’t that is my problem, aortic regurg. So right after S2, there is an early diastolic murmur because that is exactly at the point where the pathology begins. Once you understand that, then we can walk through some of the other important points such as, well let's pay attention. You see where it says diastolic blood pressure, on your left curve and I want you to go to the pressure-volume loop on your right side. They are also diastolic blood pressure. They are the same exact points physiologically but the manner in which it is presented is a bit different clinically it is so important, it is so significant, not a point in which you can just brush off. Is that clear? Why? Let us begin. I want to walk you through the pressure-volume loop first and then I will take you through the left ventricle pressure curve. The pressure-volume loop versus diastolic blood pressure, what is that vertical line? Isovolumetric contraction. The red dash line A, the loop A is the normal, not the line but the red dash curve, that is normal. That's isovolumetric contraction, that's normal. And you are building enough pressure so that you can do what please? So that you can then eject, open up that aortic valve. Would you tell me what that pressure should be? Take your time. What is that pressure that you are going to develop so that you can open up that aortic valve normally? Is it 120 or 80? It is 80. Now, take a look at the pressure curve on the left. You see the top, the left ventricular pressure curve, the top, the tip, the pinnacle? That should be what pressure please? In physio, you learn that as being 120. What is the pressure in which the aortic valve should open? That should be 80. Now you tell me, close your eyes, 120/80, what does 80 mean to you? Even though it is a systolic pressure or a systolic process, that 80 represents actual diastolic blood pressure. You see the significance of that. Now you might have looked at it in physio clinically how important is this. Really important.

    03:44 In aortic regurg how easy is it for you to open up that aortic valve? It is not easy, that is why your patient has a bounding pulses. Cannot be anymore dramatic. And so, therefore, you don't have to reach 80 to open up that aortic valve. Maybe drop down to 60, maybe even 50.

    04:09 Now, you tell me what is the significance of the diastolic blood pressure in both of these curves? Dramatically decreased. I want you to take a look at the pressure-volume loop on your right and the B curve, EC versus diastolic blood pressure, I want you to compare that point to the normal which is the red curve and you have your diastolic blood pressure which is normally at 80 and you find that to be decreased. Clinically how important is that? If you ask any cardiologist aortic regurg, diastolic blood pressure being dramatically decreased is point number one as being the most important diagnostic indicator. What is point number number 2? When you decrease the diastolic blood pressure so much then you tell me what pulse pressure equals. Pulse pressure equals your systolic blood pressure minus your diastolic blood pressure, right? And what if it diastolic blood pressure decreases like crazy? What happens to pulse pressure? It increases like crazy. Now that I can't help you, that's just simple math. When you decrease the diastolic blood pressure like crazy and in the formula for pulse pressure, your pulse pressure increases. The two most important parameters for aortic regurg is the dramatic decrease in diastolic blood pressure and an increase in pulse pressure. So far so good, I hope. One last little point that I need to bring up. You see where that those green line in your pressure-volume loop, A and B. Those green lines represent, you see the beginning of B and A, and there is where your aortic valve should close and in aortic regurg it doesn’t close. If your aortic valve doesn't close, then what happens to isovolumetric relaxation? You see the red dash curve and it is moving down, that is normal isovolumetric relaxation.

    05:52 In aortic regurg, you don’t have it. On your exam whatever it may be, understand all that they have to give you is a lack or deficiency of your isovolumetric relaxation and that to you ladies and gentlemen is aortic regurg. You understand this physio here, you understand the pathogenesis that I have given you and I have given you the presentation of the patient.

    06:16 How could you miss a single question? How could you never be embarrassed. In fact whenever you are attending in a rotation and a cardiologist is asking you question you are not going to be hiding in the back, you are going to be the individual moving up in the front and confidently telling them what? "This is aortic regurg doc, and this is why.

    06:36 Here are my differentials. This is what is going on with diastolic blood pressure, this is what is going on with pulse pressure."

    About the Lecture

    The lecture Aortic Regurgitation: Visualization by Carlo Raj, MD is from the course Valvular Heart Disease: Basic Principles with Carlo Raj.

    Included Quiz Questions

    1. Decrease in the diastolic blood pressure
    2. Decrease in the systolic blood pressure
    3. Decrease in the pulse pressure
    4. Late diastolic murmur
    5. Holosystolic murmur
    1. Systolic Blood Pressure - Diastolic Blood Pressure
    2. Diastolic Blood Pressure - Systolic Blood Pressure
    3. Cardiac Output x Stroke Volume
    4. Mean Arterial pressure - Diastolic Blood Pressure
    5. Mean Arterial pressure - Systolic Blood Pressure
    1. Widened (increased) pulse pressure
    2. Decreased systolic and increased diastolic blood pressure
    3. Increased systolic and diastolic blood pressure
    4. Narrow (decreased) pulse pressure
    5. A murmur in early systole

    Author of lecture Aortic Regurgitation: Visualization

     Carlo Raj, MD

    Carlo Raj, MD

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