A 68-year-old woman is referred to you for evaluation of a
She tells you she was diagnosed with a murmur and an
abnormal heart valve as a young woman.
She takes antibiotics before visiting the dentist
but says she feels well she walks two miles every day
Her physical exam show something interesting.
First of all, her systolic pressure is a little bit elevate
at 145 and her diastolic pressure is very low at 48
so there are several things that could go this -
very stiff arteries can give you this wide pulse pressure as
could a valvular lesion aortic insufficiency
or also called aortic regurgitation.
The pulse is regular at a reasonable rate, fingertip oxygen
JVP is normal, jugular venous pulse that is quite normal,
carotid pulse is very brisk.
The brisk carotid pulse and the wide pulse pressure are
suggesting to be this patient may have aortic insufficiency.
Her lungs are clear so there’s not heart failure and heart
she has a grade 2 systolic ejection murmur and a grade 2
diastolic murmur heard
at the upper right sternal border and no S3 again consistent
with an aortic regurgitation.
The systolic murmur doesn’t mean she has an aortic stenosis
it’s just because of the increased flow
that goes across an abnormal aortic valve during systole so
let’s imitate that.
So normal heart, lub-dub, lub-dub, lub-dub. Here’s her:
lub-shshdub-whoo, lub-shshdub-whoo, lub-shshdub-whoo.
So you heard there's two murmurs the systolic ejection
because of turbulence from the large flow going across the
and then the diastolic blowing murmur of aortic
She has no peripheral edema so there’s nothing in the exam
or the history that suggest heart failure.
So what's the critical factors here?
She has a history of heart disease so you’re gonna be
looking for a valvular heart disease
and of course her physical exam shows you a wide pulse
as well as signs of aortic valve disease. We do a chest
x-ray and then we’ll do a Doppler echo.
Here’s the chest x-ray - her left ventricle is enlarged, you
can see again the apex is pushing out
towards the chest wall but the lungs are clear
and in the aortic regurgitation also one has an enlarged
and you can see that on this view of the chest x-ray, the
dilated ascending aorta.
And here’s the Doppler, you can see in the rainbow color
a large amount of aortic regurgitation flowing across the
Large regurgitant jet flowing across an abnormal aortic
Other options, her blood test are all normal, kidney
functions normal which is good,
so the conclusion of the echo is that she has moderately
severe aortic insufficiency,
she has a bicuspid aortic valve.
One percent of the population is born with a two cusp aortic
valve rather than a three cusp
and the bicuspid aortic valve wears out early,
sometimes associate also with the ascending aortic aneurysm
or dilation of the ascending aorta.
The left ventricle is enlarged but has normal ejection
fraction so normal functioning
and she has an enlarged aortic route which is quite common
with a bicuspid aortic valve.
The bicuspid valve can go on to either stenosis or
regurgitation with time,
in this case it went on to aortic regurgitation and the left
in order to pump the larger end diastolic volume into the
because of the blood that flows back into the left ventricle
during diastole with the aortic regurge.
For symptomatic patients with severe
Surgery is recommended after a period of
intense medical therapy for heart failure
when the patients have reduced
ejection fraction or health risk.
And this includes, of course, diuretics
as well as vasodilators
with either an ACE inhibitor,
angiotensin receptor blocker
or with an ARNI.
As we talked
about that combination of ARB,
as well as a blocker for the breakdown
of atrial naturally peptide.
It's the same as patients
with other patients with HefRef. these
or die leaders are particularly important
in aortic regurgitation
because they encourage forward flow
as opposed to retrograde flow.
This patient's lungs are clear,
so there's not
any symptoms of heart failure
and the heart sounds are normal.
She has a grade two systolic ejection
murmur and a grade two diastolic murmur.
Her to the left sternal border
at the third or fourth intercostal space
and no S3.
consistent with aortic regurgitation,
but ventricular function
is not terrible at this point.
If the aortic regurgent volume is very large left
ventricular failure can eventually develop
and that requires replacement of the aortic valve.
Using prophylactic antibiotics
for dental work
or surgery has been a controversial area.
Some countries have actually shown
when they stop doing this
the incidence of endocarditis went up.
This was not the case
in the United States,
but there are still many practitioners
who prophylaxis patients
with bicuspid aortic valves
There will probably never be a double
blind, randomized controlled trial here.
So again, this is often shared decision
making with the patients.
I tend to use prophylactic antibiotics
with patients with bicuspid aortic valves,
but many of my colleagues do not.