Aortic Regurgitation (AR)

1) Definition

Aortic regurgitation is diastolic backflow of blood from the aorta → left ventricle (LV) due to incomplete closure of the aortic valve (leaflet disease) and/or dilation of the aortic root/ascending aorta (functional AR). ([MSD Manuals][1])

2) Classification

By time course

• Acute AR (minutes–days): sudden severe volume load → pulmonary edema, cardiogenic shock (LV has not adapted).
• Chronic AR (months–years): LV adapts with eccentric hypertrophy + dilation → long asymptomatic phase, later HF.

By mechanism (common clinical buckets)

• Primary (valve leaflet) AR: bicuspid valve, degenerative changes, rheumatic disease, infective endocarditis, trauma.
• Secondary/functional AR (aortic root/ascending aorta): hypertension-related aortic dilation, Marfan/CTD, aneurysm, dissection. ([MSD Manuals][1])

Severity (echo-based)

• Mild / Moderate / Severe using a multiparametric approach (vena contracta, regurgitant volume/fraction, EROA, flow reversal, LV size). ([ASE][2])

3) Pathophysiology (why symptoms happen)

• During diastole, regurgitant blood adds to LV filling → ↑ LV end-diastolic volume.
• Chronic compensation: eccentric hypertrophy keeps wall stress manageable; stroke volume increases.
• Hemodynamics: often wide pulse pressure (↑ SBP from large SV, ↓ DBP from runoff).
• Decompensation: progressive dilation → rising wall stress → falling EF, LV failure, ↑ LVEDP → pulmonary congestion.
• In acute AR, LV is noncompliant → rapid ↑ LVEDP → flash pulmonary edema and hypotension.

4) Causes / Triggers (high-yield)

Acute AR

• Aortic dissection involving the root
• Infective endocarditis (leaflet perforation)
• Trauma, iatrogenic (post-procedure)

Chronic AR

• Bicuspid aortic valve
• Degenerative leaflet disease
• Rheumatic heart disease
• Aortic root/ascending aorta dilation (HTN, CTD like Marfan)
• Post-inflammatory / post-endocarditis sequelae ([MSD Manuals][1])

5) Clinical Features

Symptoms (often late in chronic AR)

• Exertional dyspnea, fatigue → later orthopnea/PND
• Palpitations (high SV), awareness of heartbeat
• Angina (even without CAD: low DBP reduces coronary perfusion)

Acute AR

• Severe dyspnea, pulmonary edema, chest pain (dissection), syncope, shock.

Physical examination

• Early diastolic, high-pitched decrescendo murmur at left sternal border (best sitting forward, end-expiration)
• Wide pulse pressure, bounding pulses
• May have Austin Flint murmur (mid-diastolic rumble at apex) in severe AR
• Displaced hyperdynamic apex, S3 if LV failure ([MSD Manuals][1])

6) Investigations / Diagnosis (stepwise)

A) Baseline tests

• ECG: LVH, strain; arrhythmias possible
• CXR: cardiomegaly (chronic), pulmonary edema (acute)

B) Echocardiography (key test)

Purpose:

1. Identify mechanism (leaflet vs aortic root)
2. Grade severity (multiparametric)
3. Measure LV size/function (LVESD, LVEDD, LVEF) and aortic dimensions
4. Look for pulmonary pressures and associated lesions ([European Society of Cardiology][3])

Red flags on echo (severe physiology)

• Holodiastolic flow reversal in descending aorta
• Marked LV dilation and/or declining EF
• Large regurgitant volume/fraction (per echo criteria)

C) CT/MRI

• Aortic CT angiography if suspect dissection/aneurysm
• CMR for accurate regurgitant fraction/volume when echo is equivocal, and to quantify LV volumes.

D) Cardiac catheterization / coronary angiography

• Before surgery in appropriate age/risk to assess CAD, or if noninvasive data conflict.

7) Differential Diagnosis (murmur + wide pulse pressure)

• Pulmonary regurgitation (Graham Steell)
• Patent ductus arteriosus (continuous murmur)
• Hyperdynamic states (anemia, thyrotoxicosis) causing flow murmurs
• Aortic stenosis with AR (mixed disease)

8) Management (Acute vs Chronic) — Stepwise

A) Acute Severe AR (medical + urgent definitive treatment)

This is a surgical emergency in most cases (especially dissection or endocarditis with hemodynamic compromise). ([MSD Manuals][1])

Immediate actions

• Oxygen, IV access, monitoring; treat pulmonary edema
• Urgent echo; if dissection suspected → urgent CT angiography and surgical team.

Hemodynamic goals

• Reduce afterload to promote forward flow
• Maintain heart rate (avoid bradycardia; short diastole reduces regurg time)
• Support perfusion with inotropes if shock

Avoid

• Intra-aortic balloon pump (IABP) (worsens AR by increasing diastolic backflow)
• Pure bradycardic agents unless treating dissection with balanced strategy under specialist care.

Typical bridging drugs (ICU)

1. Sodium nitroprusside (afterload reduction) ±
2. Dobutamine (if low output/shock)

(Details in drug section below.)

B) Chronic AR (asymptomatic → symptomatic)

1) General / non-pharmacologic

• Regular follow-up, symptom education (dyspnea, reduced exercise tolerance, angina, syncope)
• Manage cardiovascular risk factors; exercise advice individualized
• Pregnancy counseling for severe AR/aortopathy (specialist).

2) Medical therapy (when useful)

• Treat systemic hypertension aggressively (afterload reduction), typically with ACE inhibitor/ARB or dihydropyridine CCB (e.g., nifedipine/amlodipine). This improves hemodynamics and is recommended particularly when surgery is not yet indicated or not possible. ([European Society of Cardiology][3])
• Diuretics for congestion symptoms.
• Beta-blocker/ARB may be used for aortopathy (e.g., Marfan) per aortic disease guidance (specialist-driven). ([AHA Journals][4])

Note: In isolated chronic severe AR with normal LV function, vasodilators are mainly for hypertension or when surgery is deferred; they are not a substitute for surgery once surgical thresholds are met.

9) Indications for Aortic Valve Intervention (key thresholds)

ACC/AHA (Valvular Heart Disease) — chronic severe AR

• Class I (do it):

* Severe AR + symptoms, or

* Severe AR + LV systolic dysfunction (LVEF ≤55%) (if no other cause). ([American College of Cardiology][5])

• Class IIa (reasonable):

* Asymptomatic severe AR with severe LV dilation: LVESD >50 mm or indexed LVESD >25 mm/m². ([American College of Cardiology][5])

• Severe AR undergoing other cardiac surgery (e.g., CABG/aorta surgery) → valve surgery indicated. ([professional.heart.org][6])

ESC/EACTS (Valvular) — severe AR

ESC recommendations are similar but may use slightly different EF triggers; recent ESC slide set states surgery is recommended in severe AR with LVESD >50 mm or LVESDi >25 mm/m² (and notes small body size), or resting LVEF ≤50%, and in those undergoing CABG/ascending aorta surgery. ([European Society of Cardiology][7])

Concomitant ascending aorta/aortic root surgery (common situations)

If AR is due to bicuspid valve aortopathy or aneurysm, thresholds for replacing the aorta depend on diameter and risk factors. 2022 ACC/AHA aortic disease guidance (slide set) includes:

• BAV aortopathy: surgery recommended at ≥5.5 cm, reasonable at 5.0–5.4 cm with additional risk factors, and ≥4.5 cm when undergoing AVR (experienced team). ([professional.heart.org][8])

10) Procedure Options (overview)

• Surgical AVR (SAVR): mechanical vs bioprosthetic
• Aortic valve repair (selected centers; best when durable repair expected) ([European Society of Cardiology][7])
• TAVR is standard for many AS patients, but for pure native AR it’s more complex (lack of calcification for anchoring); used selectively with newer devices/experience (specialist decision).

11) Follow-up / Surveillance (practical)

Typical echo surveillance (asymptomatic, stable):

• Mild AR: echo about every 3–5 years
• Moderate AR: every 1–2 years
• Severe AR not meeting surgery criteria: every 6–12 months, or more often if LV is approaching thresholds or symptoms change ([American College of Cardiology][9])

12) Complications

• LV dilation → HFrEF
• Atrial/ventricular arrhythmias
• Pulmonary hypertension (late)
• Endocarditis (risk depends on valve pathology)
• Sudden decompensation (especially with acute aortic syndrome)

13) Drugs Used in AR — Full Practical Drug Reference

Below are common drugs used in AR contexts (acute stabilization, chronic symptom control, HTN, HF, and aortopathy). Doses are typical adult ranges; adjust for renal function, BP, local protocols, and clinician judgment.

A) Sodium Nitroprusside (IV) — acute severe AR afterload reduction

Indication

• ICU bridge in acute severe AR (or severe decompensated chronic AR) with adequate BP, to reduce regurgitant fraction and improve forward flow.

Mechanism

• Direct NO donor → arterial + venous vasodilation → ↓ afterload and preload.

Usual dosing

• Adult: start 0.3–0.5 mcg/kg/min IV infusion, titrate; common max 10 mcg/kg/min (use lowest effective; avoid prolonged high-dose).
• Pediatrics: specialist-only; typical 0.3–8 mcg/kg/min in ICU protocols.

PK (summary)

• Immediate onset; very short half-life; metabolized to cyanide/thiocyanate (risk with prolonged/high dose, renal/hepatic dysfunction).

Adverse effects

• Hypotension, reflex tachycardia
• Cyanide/thiocyanate toxicity (confusion, metabolic acidosis; tinnitus, seizures)

Contraindications / cautions

• Severe hypotension; caution in renal/hepatic impairment, pregnancy.

Interactions

• Additive hypotension with other vasodilators, PDE-5 inhibitors.

Monitoring

• Continuous BP (arterial line ideally), acid–base status, lactate if concern, renal function; watch for toxicity if prolonged.

Counselling

• ICU drug; explain purpose is temporary stabilization before definitive intervention.

B) Dobutamine (IV) — inotrope for low-output states

Indication

• Acute AR with cardiogenic shock/low output (often with vasodilator), bridging to surgery.

Mechanism

• Predominantly β1 agonist → ↑ contractility, mild vasodilation.

Usual dosing

• Adult: 2–20 mcg/kg/min IV, titrate.
• Pediatrics: 2–20 mcg/kg/min (ICU specialist).

PK

• Rapid onset; short half-life (~2 min).

Adverse effects

• Tachyarrhythmias, ischemia, hypotension (sometimes), headache.

Contraindications/cautions

• Caution in atrial fibrillation with rapid ventricular response; severe outflow obstruction states.

Monitoring

• ECG, BP, urine output, lactate/perfusion.

C) ACE Inhibitors (e.g., Enalapril, Lisinopril) — chronic AR with HTN/HF

Indications

• Hypertension in chronic AR
• Symptomatic LV dysfunction/HFrEF (standard HF indication)
• Post-op or concomitant HTN.

Mechanism

• ↓ Ang II, ↓ aldosterone → afterload reduction.

Usual dosing

• Enalapril (adult): 2.5–5 mg daily → titrate to 10–20 mg/day (often divided).
• Lisinopril (adult): 2.5–10 mg daily → 20–40 mg daily.
• Pediatrics: varies by age/weight; typical enalapril 0.05–0.6 mg/kg/day in divided doses (specialist/peds cardiology).

PK

• Enalapril is prodrug; renal excretion (dose adjust in CKD).

Common adverse effects

• Cough, dizziness, hypotension, hyperkalemia, creatinine rise.

Serious

• Angioedema, severe renal failure (bilateral RAS), fetal toxicity.

Contraindications

• Pregnancy, history of angioedema, bilateral renal artery stenosis, K⁺ high.

Drug–drug interactions

• K⁺-sparing diuretics, supplements → hyperkalemia
• NSAIDs + ACEi + diuretic → AKI risk (“triple whammy”)
• Lithium (↑ levels)

Monitoring

• BP, K⁺/creatinine 1–2 weeks after start/titration.

Counselling

• Rise slowly from sitting; avoid salt substitutes with potassium; seek help for facial swelling.

D) ARBs (e.g., Losartan) — alternative to ACEi; aortopathy contexts

Indications

• ACEi intolerance; HTN in chronic AR
• Used in aortic disease management strategies (specialist-led) ([AHA Journals][4])

Mechanism

• Blocks AT1 receptor → ↓ afterload/aldosterone.

Usual dosing

• Adult losartan: 25–50 mg daily → 50–100 mg daily
• Pediatrics: weight-based specialist dosing (commonly 0.7 mg/kg up to 50 mg/day depending on indication).

Adverse/contraindications/interactions/monitoring

• Similar to ACEi except cough/angioedema less common (but not zero).

E) Dihydropyridine CCBs (e.g., Nifedipine/Amlodipine) — afterload reduction for HTN

Indications

• Hypertension in chronic AR; sometimes used when ACEi/ARB not tolerated.

Mechanism

• Arteriolar vasodilation → ↓ afterload.

Usual dosing

• Amlodipine (adult): 2.5–5 mg daily → 10 mg daily
• Nifedipine ER (adult): 30 mg daily → 60–90 mg daily
• Peds: specialist dosing.

Adverse effects

• Ankle edema, headache, flushing, gingival hyperplasia; reflex tachycardia (more with short-acting—avoid short-acting).

Contraindications/cautions

• Severe hypotension; caution in advanced HF (amlodipine generally safer than many others).

Monitoring

• BP, edema, HR.

F) Loop Diuretics (e.g., Furosemide) — congestion relief

Indications

• Pulmonary/systemic congestion in decompensated chronic AR or acute pulmonary edema support (not definitive).

Mechanism

• Loop Na-K-2Cl inhibition → diuresis.

Usual dosing

• Adult: 20–40 mg PO/IV; titrate (IV faster).
• Peds: 0.5–2 mg/kg/dose (specialist).

Adverse effects

• Hypokalemia, hyponatremia, volume depletion, ototoxicity (high IV doses).

Monitoring

• Weight, urine output, electrolytes, renal function.

G) Beta-blockers (context-dependent)

In isolated severe AR: aggressive HR lowering can theoretically increase regurg time; use is individualized.

In aortopathy (e.g., Marfan/aneurysm): beta-blockers/ARBs may be used to reduce aortic wall stress per aortic disease guidance (specialist-based). ([AHA Journals][4])

H) Anticoagulation (if mechanical valve or other indications)

• After mechanical AVR: long-term warfarin with INR target depending on valve type/risk (managed by cardiology).
• Not a routine AR drug unless another indication exists.

14) Infective Endocarditis (IE) Prophylaxis — practical

IE prophylaxis for dental procedures is restricted to highest-risk cardiac conditions (e.g., prosthetic valves, prior IE, certain congenital heart disease, cardiac transplant with valvulopathy). It is not recommended for most native valve lesions alone. ([www.heart.org][10])

15) External Links (Working)

(Links provided in a code block so they remain valid/clickable and comply with formatting rules.)

`text

ACC/AHA 2020 Valvular Heart Disease Guideline (full guideline article):

https://www.ahajournals.org/doi/10.1161/CIR.0000000000000923

ACC “Ten Points to Remember” summary (includes AR surgery thresholds LVEF ≤55%, LVESD >50 mm / >25 mm/m²):

https://www.acc.org/Latest-in-Cardiology/ten-points-to-remember/2020/12/16/21/58/2020-ACC-AHA-VHD-GL-Pt-1-GL-VHD

ESC/EACTS 2021 Valvular Heart Disease Guideline (EuroIntervention page):

https://eurointervention.pcronline.com/article/2021-esc-eacts-guidelines-for-the-management-of-valvular-heart-disease

ESC 2025 Valvular Heart Disease official slides (includes severe AR intervention thresholds):

https://www.escardio.org/static-file/Escardio/Guidelines/Products/Slide%20sets/2025/2025%20official%20slides_VHD.pdf

2022 ACC/AHA Aortic Disease Guideline – slide set (BAV aortopathy thresholds: ≥5.5 cm; ≥4.5 cm with AVR, etc.):

https://professional.heart.org/-/media/PHD-Files-2/Science-News/2/2022/2022-Aortic-Disease-Guideline-Slide-Set.pdf

AHA Infective Endocarditis prevention wallet card (antibiotic prophylaxis):

https://www.heart.org/-/media/files/health-topics/infective-endocarditis/infective-endocarditis-wallet-card.pdf

ADA summary page on antibiotic prophylaxis for dental procedures:

https://www.ada.org/resources/ada-library/oral-health-topics/antibiotic-prophylaxis

MSD Manual (Professional) — Aortic Regurgitation overview:

https://www.msdmanuals.com/professional/cardiovascular-disorders/valvular-disorders/aortic-regurgitation

Mayo Clinic — Aortic valve regurgitation diagnosis & treatment (patient-friendly):

https://www.mayoclinic.org/diseases-conditions/aortic-valve-regurgitation/diagnosis-treatment/drc-20353135

`

If you want, I can also generate FAQ JSON and hard case-based MCQ JSON (15) for aortic regurgitation in your exact format.

[1]: https://www.msdmanuals.com/professional/cardiovascular-disorders/valvular-disorders/aortic-regurgitation?utm_source=chatgpt.com "Aortic Regurgitation - Cardiovascular Disorders"

[2]: https://www.asecho.org/wp-content/uploads/2017/04/2017VavularRegurgitationGuideline.pdf?utm_source=chatgpt.com "Recommendations for Noninvasive Evaluation of Native ..."

[3]: https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-18/chronic-aortic-regurgitation-diagnosis-and-therapy-in-the-modern-era?utm_source=chatgpt.com "Chronic aortic regurgitation: diagnosis and therapy in the ..."

[4]: https://www.ahajournals.org/doi/10.1161/CIR.0000000000001106?utm_source=chatgpt.com "2022 ACC/AHA Guideline for the Diagnosis and ..."

[5]: https://www.acc.org/Latest-in-Cardiology/ten-points-to-remember/2020/12/16/21/58/2020-ACC-AHA-VHD-GL-Pt-1-GL-VHD?utm_source=chatgpt.com "2020 ACC/AHA Heart Valve Disease Guideline"

[6]: https://professional.heart.org/en/science-news//-/media/PHD-Files-2/Science-News/2/2020/2020_ACC_AHA_Guideline_for_the_Management_of_Patients_with_Valvular_Heart_Disease_Slide_Set.pdf?utm_source=chatgpt.com "2020 ACC/AHA Guideline for the Management of Patients ..."

[7]: https://www.escardio.org/static-file/Escardio/Guidelines/Products/Slide%20sets/2025/2025%20official%20slides_VHD.pdf?utm_source=chatgpt.com "ESC/EACTS Guidelines for the management of valvular ..."

[8]: https://professional.heart.org/-/media/PHD-Files-2/Science-News/2/2022/2022-Aortic-Disease-Guideline-Slide-Set.pdf?utm_source=chatgpt.com "2022-Aortic-Disease-Guideline-Slide-Set. ..."

[9]: https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2017/08/30/00/52/2017-appropriate-use-criteria-for-multimodality-imaging-in-vhd?utm_source=chatgpt.com "2017 Appropriate Use Criteria for Multimodality Imaging in ..."

[10]: https://www.heart.org/-/media/files/health-topics/infective-endocarditis/infective-endocarditis-wallet-card.pdf?utm_source=chatgpt.com "PREVENTION OF INFECTIVE ENDOCARDITIS"

Below are 20 detailed, exam-oriented clinical case scenarios on Aortic Regurgitation, written in a stepwise, decision-making style (presentation → key findings → diagnosis → management focus).

They are suitable for UG/PG exams, case discussions, OSCEs, and clinical reasoning practice.

1. Acute AR due to Aortic Dissection

Presentation:

A 48-year-old man presents with sudden tearing chest pain radiating to the back, severe dyspnea, and syncope.

Key findings:

• BP 80/40 mmHg, tachycardia
• Soft early diastolic murmur
• Pulmonary edema
• CXR: widened mediastinum
• Echo: severe AR, intimal flap

Diagnosis: Acute severe AR secondary to Stanford type A aortic dissection

Management:

Urgent CT aortography → emergency surgical repair with aortic valve intervention

2. Acute AR due to Infective Endocarditis

Presentation:

A 35-year-old IV drug user presents with fever, dyspnea, and acute pulmonary edema.

Key findings:

• New early diastolic murmur
• Hypotension
• Echo: perforated aortic leaflet with severe AR
• Positive blood cultures

Diagnosis: Acute AR due to infective endocarditis

Management:

IV antibiotics + urgent surgical valve replacement

3. Chronic AR – Long Asymptomatic Phase

Presentation:

A 40-year-old man detected incidentally with an early diastolic murmur during routine exam.

Key findings:

• Bounding pulse, wide pulse pressure
• Echo: severe AR, LVEF 65%, LV dilated

Diagnosis: Asymptomatic severe chronic AR

Management:

Regular echo surveillance, BP control, patient education

4. Chronic AR with Surgical Indication (EF Drop)

Presentation:

A 58-year-old man with known AR develops mild exertional dyspnea.

Key findings:

• Echo: LVEF 52%, LVESD 51 mm
• Severe AR

Diagnosis: Severe chronic AR with LV systolic dysfunction

Management:

Aortic valve replacement (Class I indication)

5. AR with Angina and Normal Coronaries

Presentation:

A 55-year-old man complains of exertional chest pain.

Key findings:

• Wide pulse pressure
• Normal coronary angiogram
• Severe AR on echo

Diagnosis: Angina due to reduced diastolic coronary perfusion

Management:

Surgical AVR

6. Marfan Syndrome with AR

Presentation:

A 28-year-old tall male with long limbs presents for evaluation.

Key findings:

• Aortic root dilation
• Moderate AR
• Family history of sudden death

Diagnosis: AR due to aortic root dilation (Marfan syndrome)

Management:

Beta-blocker or ARB, serial imaging, elective surgery if thresholds reached

7. Austin Flint Murmur Case

Presentation:

A 60-year-old man has exertional dyspnea.

Key findings:

• Early diastolic murmur at LSB
• Mid-diastolic rumble at apex
• No opening snap

Diagnosis: Severe AR with Austin Flint murmur

Management:

Evaluate LV size and plan surgery

8. Acute AR with Absent Murmur

Presentation:

A 50-year-old man with acute pulmonary edema.

Key findings:

• Hypotension
• Very faint or absent murmur
• Echo: torrential AR

Diagnosis: Acute severe AR

Management:

Urgent surgery; murmur absent due to pressure equalization

9. Bicuspid Aortic Valve AR

Presentation:

A 32-year-old man with exertional dyspnea.

Key findings:

• Systolic click
• Echo: bicuspid valve, severe AR
• Dilated ascending aorta

Diagnosis: AR due to bicuspid aortic valve

Management:

AVR ± ascending aorta replacement

10. AR with Hypertension

Presentation:

A 65-year-old hypertensive patient with mild dyspnea.

Key findings:

• BP 170/60 mmHg
• Moderate AR on echo

Diagnosis: Chronic AR worsened by uncontrolled hypertension

Management:

ACE inhibitors / ARBs, BP control, echo follow-up

11. AR in Pregnancy

Presentation:

A 30-year-old pregnant woman with known AR presents in second trimester.

Key findings:

• Mild dyspnea
• Echo: moderate AR, preserved EF

Diagnosis: Chronic AR in pregnancy

Management:

Medical management, avoid surgery unless life-threatening

12. AR with Heart Failure

Presentation:

A 60-year-old man presents with orthopnea and PND.

Key findings:

• S3 gallop
• Severe AR
• EF 45%

Diagnosis: Decompensated chronic AR with HFrEF

Management:

Diuretics, vasodilators, urgent AVR

13. Holodiastolic Flow Reversal Case

Presentation:

A 52-year-old asymptomatic patient under follow-up.

Key findings:

• Echo: holodiastolic flow reversal in descending aorta

Diagnosis: Severe AR despite minimal symptoms

Management:

Assess LV dimensions → likely surgery

14. AR with Atrial Fibrillation

Presentation:

A 64-year-old man with palpitations and dyspnea.

Key findings:

• Irregularly irregular pulse
• LA enlargement
• Severe AR

Diagnosis: Chronic AR with AF

Management:

Rate control, anticoagulation, valve surgery

15. Post-Rheumatic AR

Presentation:

A 55-year-old woman with history of rheumatic fever.

Key findings:

• AR murmur
• Associated mitral valve disease

Diagnosis: Rheumatic mixed valve disease with AR

Management:

Combined valve assessment and surgical planning

16. AR with LVESD Index Crossing Threshold

Presentation:

Asymptomatic patient on surveillance.

Key findings:

• Indexed LVESD = 26 mm/m²
• EF preserved

Diagnosis: Severe AR with surgical criteria met

Management:

Elective AVR

17. AR with Syncope

Presentation:

A 58-year-old collapses during exertion.

Key findings:

• Severe AR
• Reduced cerebral perfusion due to low diastolic BP

Diagnosis: Advanced AR with hemodynamic compromise

Management:

Urgent valve replacement

18. AR with Endocarditis Prophylaxis Question

Presentation:

A patient with native AR asks about dental extraction.

Key findings:

• No prior endocarditis
• Native valve only

Diagnosis: Chronic AR without high-risk features

Management:

No antibiotic prophylaxis indicated

19. AR with MRI Confirmation

Presentation:

A patient with discordant echo findings.

Key findings:

• Echo inconclusive
• MRI: regurgitant fraction 55%

Diagnosis: Severe AR confirmed by cardiac MRI

Management:

Surgical referral

20. Delayed Surgery Consequence

Presentation:

A patient delayed AVR despite indications.

Key findings:

• EF now 35%
• Persistent LV dilation post-AVR

Diagnosis: Irreversible LV dysfunction due to delayed surgery

Management:

Heart failure therapy + guarded prognosis