Aspirational diastolic murmur

Specialty: Cardiovascular.

• diastolic regurgitation murmur
• aortic or pulmonary insufficiency murmur

Why it occurs

• Aortic valve insufficiency (secondary to bicuspid valve disease, rheumatic fever, endocarditis or aortic root dilation)
• High-pressure pulmonary valve regurgitation (Graham Steell murmur, secondary to severe pulmonary arterial hypertension)
• Aortic dissection with retrograde involvement of the aortic valve annulus
• Infective endocarditis of the aortic or pulmonary valve with destruction of leaflets
• Marfan syndrome with annuloaortic ectasia and severe aortic reflux

Initial workup

Emergency transthoracic and transesophageal echocardiogram (TEE) to assess the morphology of the affected valve, measure the magnitude of the reflux (jet width, regurgitant volume), rule out dissection of the ascending aorta (presence of intimal flap) and visualize possible vegetations or annular abscesses; 12-lead electrocardiogram; Multidetector computed tomography (CT-Angio) of the chest; Serial blood cultures if infective endocarditis is suspected.

Standard management

• Ceftriaxone combined with Ampicillin — empirical intravenous antibiotic therapy indicated if acute infective endocarditis with valve destruction is suspected; ceftriaxone 2 g every 12 hours IV and ampicillin 2 g every 4 hours IV, after taking blood cultures
• Sodium nitroprusside — arterial vasodilator indicated to rapidly reduce afterload in severe acute aortic insufficiency not associated with dissection, favoring antegrade flow; continuous infusion of 0.3 to 3 mcg/kg/min with invasive monitoring
• Dobutamine — inotrope indicated if there is concomitant severe systolic ventricular failure; infusion of 2.5 to 5 mcg/kg/min
• Metoprolol (beta-blocker indicated only if the diastolic murmur is associated with stable type B aortic dissection for strict control of rate and blood pressure; 5 mg slow intravenous under close monitoring).