Sunday, June 28, 2009

Eponymous Signs of Aortic Regurgitation

Austin Flint Murmur


The murmur typically begins in mid-diastole, often has a presystolic accentuation, and terminates at the end of diastole. It is low-pitched, with a rough and rumbling quality, and best heard at the apex. An Austin Flint murmur can be deemed present only in the setting of aortic regurgitation without coexisting mitral stenosis, since the latter can generate a similar murmur.


Austin Flint postulated that regurgitant blood flow in severe aortic regurgitation impinges on the leaflets of the mitral valve, leading to a functional stenosis. Diastolic inflow across this narrowed mitral valve orifice generates turbulence that is clinically appreciable as a mid- to late diastolic murmur . Later investigations have advanced a variety of other theories as causes for the murmur, including overlap of aortic regurgitation and mitral inflow jets , fluttering of mitral valve leaflets (, and left ventricular endocardial vibrations due to the aortic regurgitation jet. However, a universally accepted explanation remains elusive.


The murmur is best heard on auscultation at the apex by using the bell of the stethoscope, with the patient in the left lateral position.


Corrigan Pulse:


Large volume collapsing pulse of the carotid artery


A recent investigation found that patients with aortic regurgitation had increased amplitude of the pulse, lower mean arterial pressure, and narrower pulse pressure than normal patients . The investigators concluded that these characteristics reflected an increase in the compliance of the arterial wall in patients with aortic regurgitation.


The examiner palpates the patient's radial artery while elevating the wrist. If the pulse clearly increases in amplitude, then the sign is present.


Duroziez Sign


The sign denotes an intermittent to-and-fro femoral artery murmur (occurring in systole and diastole, respectively) generated by femoral artery compression.


Duroziez believed the systolic portion of the murmur was caused by forward flow into the lower extremity and that the diastolic segment was caused by aortic regurgitation toward the heart.


Duroziez auscultated the femoral artery while applying digital compression proximal and distal to the stethoscope .Blumgart and Ernstene  ) replaced digital compression with cephalad and caudad tilting of the stethoscope.


Hill Sign:This sign is also known as the popliteal–brachial gradient.


A 20 mmHg difference in the popliteal and brachial systolic cuff pressures


The Hill sign, therefore, remains an unexplained artifact of indirect blood pressure measurement that is consistently more common and pronounced in patients with aortic regurgitation than in those without.


The blood pressure is manually obtained over the brachial and femoral arteries by using appropriately sized cuffs, with the patient in the recumbent position. The difference in systolic pressures denotes the gradient.


Watson’s water hammer pulse: also known as collapsing pulse, cannonball pulse or pulsus celer.


Large-volume, ‘collapsing’ bounding peripheral pulses.


The abrupt jerky, forceful upstroke of the whp implies a rapid filling of the radial artery in systole due to an extra large amount of blood pushed by the distended left ventricle into relatively empty arterial vessels. The collapsing or sudden down stroke may be partly due to a sudden fall in the diastolic pressure in the aorta due to regurgitation of blood into the left ventricle through a leaky valve and partly due to the rapid emptying of the arterial system due to the marked increase in the velocity of the bloodstream. Apart from the pathogenetic factors which cause the widened pulse pressure, lifting the patient's arm vertically upwards when eliciting the whp, helps the blood to empty quickly into the heart during diastole due to the gravity and also brings the radial artery more in line with the outflow stream of the aorta, thus accentuating the sign.


Traube’s sign/pistol shot sounds :

Booming systolic and diastolic sounds heard over the femoral artery when it is compressed distally

De Musset’s sign: Head nodding with each heart beat

Quincke’s sign :Pulsations in the nail capillary bed seen when light is transmitted through the fingertips or exerting gentle pressure on the tip of a fingernail .

Lighthouse sign:Blanching and flushing of forehead

Landolfi’s sign :Alternating constriction and dilatation of pupil

Becker’s sign :Visible pulsations of the retinal arterioles

Mueller’s sign :Visible pulsations of uvula

Mayen’s sign :Diastolic drop of BP >15 mmHg with arm raised

Rosenbach’s sign :Pulsatile liver

Lincoln sign :Pulsatile popliteal artery

Gerhardt’s sign : Pulsatile spleen

Sherman sign: Prominently located and palpated dorsalis pedis pulse


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Anonymous said...

The Austin Flynt murmur has a mid-DIASTOLIC crescendo (not systolic). To help distinguish it from Mitral stenosis, it will (in general) be more harsh than MS and associated with a widened pulse pressure (Sys press-Dias press, normal ~40-50). It will also be generally be louder at the R upper Sternal border at Angle of Louie. Also associated with Watson's pulse

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