At the beginning there is the external examination by simply looking at the patient. If chronic aortic valve insufficiency is present, the first signs may already be visible here, such as the pulse-synchronous nodding of the head. The measurement of blood pressure, for example, yields values of 180/40 mmHg.
If the values measured in the legs are compared with the values measured in the arms, the systolic blood pressure of the legs can be 60 mmHg above that of the arms. When subsequently palpating body structures, the so-called pulsus celer et altus, i.e. a large and rapid pulse, is noticeable in chronic aortic valve insufficiency. The apex of the heart, i.e. the palpable beating of the apex of the heart against the chest wall, is also increased during palpation and shifted downwards and to the left.
These symptoms are absent in acutely occurring aortic valve insufficiency. For further diagnosis, listening with a stethoscope and the electrocardiogram (ECG) play a role. In acute aortic valve insufficiency the ECG is normal.
Even in mild to moderate chronic aortic valve insufficiency, the ECG may still appear normal; with increasing severity, signs of an increase in muscle mass of the left ventricle appear. Furthermore, certain signs can also be detected in an X-ray of the heart. In acute aortic valve insufficiency, the heart itself is unremarkable, but signs of pulmonary congestion can be detected.
If, on the other hand, chronic aortic valve insufficiency is present, the heart is widened on the X-ray. Echocardiography, i.e. ultrasound examination of the heart, is the fastest and best method of examining acute or chronic aortic valve insufficiency today. It can be performed either by placing the ultrasound probe on the chest (so-called transthoracic echocardiography, TTE) or from the esophagus, where the patient has to swallow a tube with an ultrasound probe (so-called transesophageal echocardiography, TEE).
Usually, however, the ultrasound examination from the surface of the chest is sufficient. With the help of this ultrasound examination, the diagnosis can be confirmed and it can be determined how much blood flows back through the aortic valve into the left chamber. Finally, a left heart catheter examination can also provide information.
This is done as soon as the diagnostic methods listed above do not provide sufficient information. The heart murmurs that can be heard during the physical examination by stethoscope can be deduced from the disease mechanism. In healthy people a first and a second heart sound can be heard.
The first marks the beginning of systole (ejection phase), the second the beginning of diastole (filling phase). Since in aortic valve insufficiency blood flows back into the left ventricle during diastole, a softer flow noise (so-called early diastolic decrescendo noise) can be heard shortly after the second heart tone. In cases of severe aortic valve insufficiency the so-called Austin flint noise may also occur, which has a rather rumbling character, begins in the middle of the diastole and extends into early systole.
The ultrasound or echography of the heart is the best method of examination to detect pathological changes. It can be performed from the outside through the wall of the chest or, under short anaesthesia, through the oesophagus. Particularly important is the colour Doppler examination, which can be used to observe flow movements.
In a healthy heart, the valves should close tightly during the heart action. In the case of insufficiency, however, during diastole, i.e. the filling phase of the ventricles, a backflow into the ventricle through the leaking valve can be seen. This can be represented in the colour Doppler as a so-called jet.