Systolic aortic regurgitation in rheumatic carditis: Mechanistic insight by Doppler echocardiography

Aortic regurgitation (AR) usually occurs in diastole in presence of an incompetent aortic valve. Systolic AR is a rare phenomenon occurring in patients with reduced left ventricular systolic pressure and atrial fibrillation or premature ventricular contractions. Its occurrence is a Doppler peculiarity and adds to the hemodynamic burden.

Rheumatic carditis is often characterised by acute or subacute severe mitral regurgitation (MR) due to flail anterior mitral leaflet and elongated chords. In patients with acute or subacute MR, developed left ventricular systolic pressure may fall in mid and late systole due to reduced afterload and end-systolic volume and may be lower than the aortic systolic pressure, causing flow reversal in aorta and systolic AR.

17 patients with acute rheumatic fever were studied in the echocardiography lab during the period 2005-2015. Five patients had severe MR of which two had no AR and hence were excluded from the study. Three young male patients (age 8-24 years) who met modified Jones' criteria for rheumatic fever with mitral and aortic valve involvement were studied for the presence of systolic AR.

In presence of acute or subacute severe MR, flail anterior mitral valve and heart failure, all three showed both diastolic and late systolic AR by continuous-wave and color Doppler echocardiography.

Systolic AR is a unique hemodynamic phenomenon in patients with acute rheumatic carditis involving both mitral and aortic valves and occurs in presence of severe MR.