1. What are the most common causes of severe AR (a) in the child, and (b) in the adult?
ANS: a. In the young child, a VSD with aortic valve prolapse may be the most common cause of severe AR. b. In the adult, rheumatic heart disease, endocarditis, or paraprosthetic valve leaks are probably equally common as causes of severe AR.
2. What is the most common cause of mild AR in the adult? Why?
ANS: Severe hypertension. In one series of severely hypertensive patients, 60% had AR . When the diastolic pressure is reduced below 115 mmHg, the AR may disappear. Two causes have been suggested: (a) dilatation of the aortic annulus and (b) high pressure above a bicuspid or fenestrated aortic valve.
Note: a. Bicuspid aortic valves occur in about 2% of males and 1% of females.
b. Fenestrations are common in both aortic and pulmonary valves.
c. The aortic annulus is not significantly dilated at systolic pressures below 170, or diastolic-pressures below 105.
3. List some rare causes of AR (a) with arthritis and (b) without arthritis.
ANS: a. With arthritis:
(1) Ankylosing spondylitis.
(2) Reiter's syndrome. In about 5% with this syndrome, AR may be found from 1 to 20 years after diagnosis.
(3) Rheumatoid or psoriatic arthritis.
b. Without arthritis:
(1) Syphilis (leutic aortitis).
(2) Osteogenesis imperfecta. The AR here is due to dilatation of the aortic root.
(3) Dissecting aneurysm of the ascending aorta.
(4) Rupture of a sinus of Valsalva.
(5) The Marfan syndrome. The AR is due to dilatation of the aortic root and myxomatous degeneration of the cusps.
Note: Although both males and females with the Marfan syndrome may have MR, only males (usually under age 40) develop AR. Although myxomatous transformation of the aortic valve is characteristic of the Marfan syndrome, it can occur without this syndrome; when it does, it can result in rupture of an aortic cusp.
4. What should make you suspect by auscultation that a bicuspid aortic valve is the cause of the AR?
ANS: Mild AR plus an ejection click followed by an early ejection murmur that is loudest in the second right interspace. The A2 may also be loud and snapping.
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