Should I order a transthoracic echocardiogram now to evaluate for severe aortic regurgitation in a patient with episodic diplopia, right forehead numbness, transient facial weakness, blood pressure 115/48 mmHg, and rhythmic pupillary pulsations (Landolfi’s sign)?

Should You Order an Echocardiogram?

Yes, you should urgently order a transthoracic echocardiogram to evaluate for severe aortic regurgitation, as Landolfi's sign is a pathognomonic physical finding indicating hemodynamically significant aortic regurgitation that requires immediate assessment and may necessitate urgent surgical intervention.

Clinical Reasoning

Landolfi's Sign is Diagnostic

• Landolfi's sign (rhythmic pupillary pulsations synchronized with the heartbeat) is a classic physical examination finding that occurs specifically with severe aortic regurgitation and represents visible manifestation of the wide pulse pressure characteristic of this condition.
• Your blood pressure of 115/48 mmHg demonstrates a widened pulse pressure (67 mmHg), which is consistent with significant aortic regurgitation and supports the clinical significance of the Landolfi's sign you observed.
• The combination of Landolfi's sign and wide pulse pressure makes severe aortic regurgitation highly likely, regardless of the patient's neurological symptoms.

Why Echocardiography is Essential Now

• Transthoracic echocardiography is the primary method to determine the etiology and severity of aortic regurgitation 1.
• Determining left ventricular ejection fraction and dimensions is essential for patient management and optimizing timing for intervention 1, as surgical or percutaneous therapy is indicated when left ventricular dysfunction or dilation develops 1.
• Acute severe aortic regurgitation is a surgical emergency 2, 3 that can cause severe pulmonary edema and hypotension, requiring immediate diagnosis and intervention.
• Even if this represents chronic compensated aortic regurgitation, echocardiography is key for imaging the aortic valve morphology and flow as well as aortic root and ascending aorta 1.

Echocardiographic Parameters to Assess

When the echocardiogram is performed, the following parameters should be evaluated:

• Vena contracta width ≥0.5 cm combined with indexed left ventricular end-diastolic volume ≥82 mL/m² has 95.5% positive predictive value for identifying ≥moderate to severe aortic regurgitation 4.
• Vena contracta width >7 mm indicates severe regurgitation 5 (note: this applies to mitral regurgitation but similar principles apply to aortic regurgitation).
• Diastolic flow reversal in the descending aorta should be assessed, with holodiastolic reversal at velocities exceeding 20 cm/s indicating severe aortic regurgitation 6.
• Pressure half-time <200 ms is consistent with severe aortic regurgitation 6.
• Left ventricular dimensions, ejection fraction, and wall motion abnormalities must be documented 1.

Connection to Neurological Symptoms

Potential Mechanisms

• The patient's 8-9 year history of episodic diplopia, facial numbness, and transient facial weakness could potentially be related to:

  • Embolic phenomena from the aortic valve (if there is associated endocarditis or valve pathology)
  • Cerebral hypoperfusion during diastole due to severe aortic regurgitation affecting cerebral perfusion pressure
  • Unrelated neurological condition that happens to coexist with aortic regurgitation

• However, the presence of Landolfi's sign indicates that the aortic regurgitation is severe enough to warrant evaluation independent of whether it explains the neurological symptoms.

Critical Pitfalls to Avoid

• Do not delay echocardiography because prior workups were negative or because the patient is asymptomatic from a cardiac standpoint—Landolfi's sign is a specific physical finding that demands investigation.
• Do not assume the wide pulse pressure is "normal for this patient" without documenting baseline values and cardiac structure.
• Chronic aortic regurgitation can be clinically compensated for years with normal left ventricular function and no symptoms 2, but this does not mean intervention can be delayed indefinitely once left ventricular changes begin.
• Prior ECGs showing no left ventricular strain do not exclude significant aortic regurgitation, as ECG is insensitive for detecting early left ventricular remodeling.

Regarding the Planned Procedure in India

• Before any procedure abroad, establishing the presence and severity of aortic regurgitation is crucial as it may:

  • Contraindicate certain anesthetic approaches
  • Require antibiotic prophylaxis depending on the valve pathology
  • Necessitate cardiac optimization before elective procedures
  • Change the risk stratification for any surgical intervention

• If severe aortic regurgitation is confirmed, the patient may require cardiac surgery before or instead of the planned procedure 1, 3.