Peripheral signs of aortic regurgitation

Peripheral signs of aortic regurgitation

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Color Doppler echo in Aortic Regurgitation (AR). Left panel shows the Doppler tracing from the left ventricular outflow tract (LVOT) with the tongue shaped upward AR jet and the conical downward jet of forward flow in the LVOT. Right panel from the apical five chamber view shows the mosaic AR jet from the aortic valve into the LVOT and well into left ventricular cavity. The continuous wave Doppler cursor can be seen across the LVOT.

Peripheral signs of AR are mostly due to the high stroke volume and high pulse pressure. They are noted in severe AR (free AR). These are features of aortic runoff and can occur in other situations of aortic runoff like a ruptured sinus of Valsalva into right atrium.

  1. Arterial pulsations in the retina: Normally there are only venous pulsations visible on the ocular fundus. In aortic regurgitation, retinal arterial pulsations are visible. This is known as Becker’s sign.
  2. Muller’s sign: Systolic pulsations of the uvula in aortic regurgitation.
  3. Dancing carotids: Prominent carotid pulsations due to the wide pulse pressure in aortic regurgitation (Corrigan’s sign).
  4. de- Musset’s sign: Head nodding sign in aortic regurgitation.
  5. Bisferiens pulse is more suggestive of free aortic regurgitation than a combination of aortic stenosis and regurgitation. Bisferiens pulse has two peaks in each systole.
  6. Locomotor brachii is a prominent pulsation of brachial artery seen in aortic regurgitation. It can also be seen in elderly individuals without aortic regurgitation.
  7. Collapsing pulse or water hammer pulse is noted in the radial artery, with upper limb lifted up passively and felt by the palm of the hand. Water hammer was a toy in the Victorian era in which fall of water in vacuum tube produces a characteristic feel.
  8. Quincke’s sign: Prominent nail bed capillary pulsations.
  9. Duroziez murmur / sign: A stethoscope kept over the femoral artery picks up a systolic murmur with proximal compression and diastolic murmur with distal compression. The diastolic murmur is specific.
  10. Pistol shots sounds can be heard over the femoral arteries and sometimes over the brachial arteries (Traube’s sign).
  11. Gerhardt’s sign: Hepatic pulsations in severe aortic regurgitation.
  12. Rosenbach’s sign: Splenic pulsations in severe aortic regurgitation.
  13. Mayne’s sign: Exaggerated decrease in diastolic blood pressure (more than 15 mm Hg) on raising the upper limb. But the validity has been questioned as this can be noted in younger age without aortic regurgitation [1].
  14. Lincoln sign: Prominent popliteal artery pulsations.
  15. Sherman sign: Prominent dorsalis pedis artery pulsations.
  16. Hill’s sign: Hill’s sign [2] is based on the difference between the upper limb and lower limb arterial pressures recorded by the sphygmomanometer. Systolic pressure recorded from the lower limb is more than that from the upper limb. Difference in systolic pressure above 20 mm Hg is taken as significant. When Hill’s sign is taken for grading the severity of aortic regurgitation, the following classification is usually applied:

Mild AR: 20 – 40 mm Hg
Moderate AR: 40 – 60 mm Hg
Severe AR: More than 60 mm Hg

It may be noted that direct intra arterial recordings of axillary and femoral arterial pressures did not demonstrate any exaggerated difference in systolic pressures between them [3]. Authors suggested that Hill’s sign is an artefact of sphygmomanometric lower limb pressure measurement and has no physiological basis.

Cardio-ankle vascular index (CAVI)

Cardio-ankle vascular index (CAVI) [4], originally used to measure arteriosclerosis, has been used to assess AR objectively [5].  CAVI measurement includes pulse pressure, difference between upper limb and lower limb pressures, ankle-brachial index, ejection time and upstroke time. Calculation of CAVI uses a complex formula [4]. Shiraishi H et al concluded that CAVI parameters could be useful in screening and serial follow up of patients with aortic regurgitation. This study also documented that Hill’s sign correlated with severity of AR [5]. Ankle brachial index increased in aortic regurgitation. Hill’s sign or difference between upper limb and lower limb pressures correlated semi-quantitatively with severity of AR.

References

  1. Happes M, Kamran H, Salciccioli L, Ko EH, Lazar JM. Mayne’s sign is mainly related to younger age and not to aortic regurgitation. Blood Press Monit. 2010 Dec;15(6):305-7.
  2. Hill I, Flack M, Holtzmann W. The measurement of systolic blood pressure in man. Heart. 1909; 1: 73-82.
  3. Kutryk M, Fitchett D. Hill’s sign in aortic regurgitation: enhanced pressure wave transmission or artefact? Can J Cardiol. 1997 Mar;13(3):237-40.
  4. Shirai K, Utino J, Otsuka K, Takata M. A novel blood pressure-independent arterial wall stiffness parameter; cardio-ankle vascular index (CAVI). J Atheroscler Thromb. 2006 Apr;13(2):101-7.
  5. Shiraishi H, Shirayama T, Maruyama N, Kaimoto S, Otakara A, Kurimoto R, Nakanishi N, Nakamura T, Yamano T, Matsumuro A, Doi K, Yaku H, Matoba S. Usefulness of peripheral arterial signs in the evaluation of aortic regurgitation. J Cardiol. 2017 May;69(5):769-773.
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