Presentation depends on whether the valvular insufficiency is an acute or a chronic process.

Patients with acute aortic insufficiency have severe dyspnea, signs of cardiogenic shock (tachycardia, hypotension), cyanosis, pulmonary edema, acute heart failure (fatigability and peripheral edema) and chest pain if coronary or aortic dissection is the cause of the regurgitation [1].

Chronic aortic insufficiency leads to palpitations and dyspnea which is initially exertional and afterward occurs with minimal efforts and chest pain if coronary perfusion is compromised. As the disease progresses, orthopnea and paroxysmal nocturnal dyspnea start to occur. Angina is predominantly nocturnal in these patients. As with all valvular diseases, aortic insufficiency is prone to endocarditis, manifesting as fever and central or peripheral embolism.

Auscultation reveals single S1 and S2 sounds and a diastolic descrescendo, high-pitched murmur that increases with squatting. Systolic blood pressure tends to increase, while the diastolic component is prone to decrease.

Chronic aortic insufficiency, but not the acute form, is accompanied by several peripheral signs, reflecting increased stroke volume and wide pulse pressure: pulsation of the liver (Rosenbach), spleen (Gerhardt), retinal arterioles (Becker), cervix (Shelly), uvula (De Musset), capillaries of the nail bed (Quincke), systolic contraction and diastolic dilation of the pupil (Landolfi). In aortic insufficiency, auscultation of the femoral artery reveals systolic and diastolic sounds (Traube) and bruits if the artery is slightly compressed (Duroziez). The "water-hammer" pulse is known as Corrigan's sign, while De Musset's sign describes a specific bobbing motion of the head with each cardiac cycle. When popliteal blood pressure is at least 60 mm Hg higher than the brachial one, Hill's sign is present and if diastolic brachial pressure decreases by at least 15 mm Hg when the arm is raised above the head, Mayne's sign should be noticed. As symptoms worsen, so does the prognosis [2].

Blood workup in aortic valve insufficiency should include complete blood count, inflammatory markers, and cultures if endocarditis is suspected, coagulation parameters like prothrombin time and activated partial thromboplastin time, electrolyte panel, renal and hepatic tests and lactate dehydrogenase.

Echocardiography is a valuable and accurate tool in aortic insufficiency, allowing morphological valvular description, vegetation identification, and ascending aorta evaluation for dissection or aneurysm. Cavity dimensions and ejection fraction should be evaluated, especially if surgical intervention is needed [3].

Severe aortic valvular insufficiency is defined by certain parameters, derived from color, continuous and pulsed wave Doppler studies: vena contracta > 6 mm, regurgitant volume > 60 mL/beat, regurgitation fraction > 50%, and holodiastolic flow reversal in the descending aorta. Left ventricle dilation and ejection fraction should also be investigated, as well as pulmonary hypertension, pericardial effusion and aortic dissection [4]. Transesophageal echocardiography is especially useful in patients with poor acoustic windows or valvular calcification which makes it difficult to identify valve anatomy. An enlarged aorta may need additional characterization using computer tomography [5] or magnetic resonance imaging [6], while radionuclide imaging may be useful in further investigating left ventricular ejection fraction if echocardiography results are disproportional to clinical status.

Electrocardiography can show cavity enlargement or hypertrophy or ischemia, while chest radiography shows cardiac dilatation with valvular insufficiency is chronic and a cardiac normal size if the problem is acute in character. In addition, X-ray helps to detect pulmonary edema.

Exercise testing is indicated in order to assess functional capacity of the heart in chronic aortic regurgitation [7].

Aortic angiography is indicated if dissection is suspected while coronary angiography is performed in all patients scheduled to undergo aortic valvular replacement, in order to assess the need for a concomitant coronary bypass [8].

Treatment for aortic valve insufficiency depends on the severity of the condition and the presence of symptoms. Options include:

• Monitoring: Regular check-ups and echocardiograms to monitor the condition if symptoms are mild or absent.
• Medications: To manage symptoms and reduce the heart's workload, such as diuretics, blood pressure medications, or vasodilators.
• Surgery: In severe cases, valve repair or replacement may be necessary. This can be done through traditional open-heart surgery or minimally invasive techniques.

The prognosis for aortic valve insufficiency varies based on the severity of the condition and the timeliness of treatment. With appropriate management, many individuals can lead normal, active lives. However, if left untreated, severe aortic valve insufficiency can lead to heart failure or other serious complications.

Aortic valve insufficiency can result from various causes, including:

• Congenital heart defects: Some people are born with valve abnormalities.
• Rheumatic fever: A complication of untreated strep throat that can damage heart valves.
• Endocarditis: An infection of the heart valves.
• Aortic dissection: A tear in the aorta that can affect the valve.
• Age-related changes: Degeneration of the valve with age.

Aortic valve insufficiency is more common in older adults, as age-related changes can affect the valve's function. It is also more prevalent in men than women. The condition can occur in people of all ages, including those with congenital heart defects or a history of rheumatic fever.

In aortic valve insufficiency, the aortic valve does not close properly, allowing blood to flow backward into the left ventricle. This backward flow increases the volume of blood the heart must pump, leading to an enlarged heart and increased pressure in the heart chambers. Over time, this can weaken the heart muscle and lead to heart failure.

While some causes of aortic valve insufficiency cannot be prevented, such as congenital defects, others can be managed to reduce risk. Preventive measures include:

• Treating strep throat promptly: To prevent rheumatic fever.
• Maintaining good dental hygiene: To reduce the risk of endocarditis.
• Managing high blood pressure: To reduce strain on the heart.
• Regular check-ups: Especially for those with known heart conditions.

Aortic valve insufficiency is a condition where the aortic valve does not close properly, leading to backward blood flow into the heart. It can cause symptoms like fatigue and shortness of breath and may require treatment ranging from monitoring to surgery. Early diagnosis and management are crucial for a favorable outcome.

If you have been diagnosed with aortic valve insufficiency, it's important to follow your doctor's recommendations and attend regular check-ups. Lifestyle changes, such as maintaining a healthy diet, exercising regularly, and managing stress, can help support heart health. Understanding your condition and treatment options can empower you to make informed decisions about your care.

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