A 70-year-old man has a high-pitched early diastolic blowing murmur along the left sternal border, wide pulse pressure, and bounding peripheral pulses. Chest imaging shows a dilated ascending aorta with tree-bark intimal scarring. The mechanism of the aortic regurgitation is:

• A Fusion of aortic valve commissures by rheumatic inflammation
• B Calcification restricting cusp mobility
• C Dilation of the aortic valve annulus by aortitis ✓
• D Perforation of a cusp by infective vegetations

Explanation

Syphilitic aortitis involves the vasa vasorum of the ascending aorta, causing obliterative endarteritis, medial necrosis, and weakening that produces aneurysmal dilation of the aortic root. The valve annulus stretches, the cusps separate, and regurgitation follows even though the cusps themselves are normal. Tree-bark scarring of the intima is characteristic. Commissural fusion gives stenosis in rheumatic disease, cusp calcification restricts opening, and perforation belongs to active endocarditis.

Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.