Case of Locomotor brachii sign in aortic regurgitation
A 60-year-old man with an ischemic stroke history arrived to the cardiology clinic with a 3-month history of exertional dyspnea. His blood pressure was 141/55 mm Hg, and his pulse pressure was 86 mm Hg. There was a grade 2/6 systolic murmur and a grade 3/4 diastolic murmur in the right second intercostal area on physical examination. Carotid pulses were racing. The locomotor brachii sign was observed in both brachial arteries, which were tortuous and clearly pulsatile, swelling in systole and immediately collapsing in diastole.
Because of the broad pulse pressure and diastolic reversal of flow associated with significant valve insufficiency, the locomotor brachii sign can be detected in individuals with aortic regurgitation. Patients with extensive arteriosclerosis may also exhibit this symptom. Transthoracic echocardiography revealed a bicuspid aortic valve with severe regurgitation, a moderately enlarged left ventricle, a modestly dilated aortic root, and a normal ascending aorta in this patient. Diastolic flow reversal was discovered using spectral Doppler ultrasonography of the brachial arteries. The final diagnosis was chronic severe aortic regurgitation. The patient was referred for aortic valve replacement surgery.
A spectral doppler tracing of the brachial artery at the bedside revealed diastolic flow reversal and twofold (systolic and diastolic) bruit with brachial artery compression. This is the first report to incorporate doppler data into the Locomotor brachii sign. A bicuspid aortic valve with flail leaflet and significant eccentric aortic insufficiency was discovered on a transthoracic echo. A mechanical aortic valve was used to replace the patient’s aortic valve.
Aortic regurgitation
AI refers to insufficient closure of the aortic valve leaflets. Aortic root dilation, congenital bicuspid aortic valve, calcific valve disease, and rheumatic heart disease are the most common causes of AI.1 The failure of the aortic valve to seal during diastole causes blood to regurgitate into the left ventricle, which is also associated with a rapid drop in arterial pressure. This causes an increase in both end-diastolic and stroke volumes. The net result is an increase in systolic pressure and a drop in diastolic pressure (i.e. a narrowed pulse pressure). Corrigan pulse (collapsing pulse in carotid or brachial arteries) is one of several physical abnormalities.
The broad pulse pressure causes Landolfi’s sign2 and Traube’s sign (pistol shot pulse heard over femoral arteries). The hallmark indications of severe AI are a loud diastolic murmur, enlarged pulse pressure, and bounding arterial pulses; however, these may not always be visible or present on physical examination. The gold standard for assessing severe AI is transthoracic echocardiography with Doppler. The presence of significant pulsing of the brachial artery, as seen in severe AI and older people with extensive arteriosclerosis, is known as the locomotor brachii sign. In our patient, bedside spectral Doppler ultrasound revealed diastolic flow reversal and a twofold bruit (systolic and diastolic) with brachial artery compression.
Doppler monitoring of the brachial artery in locomotor brachialis has not before been documented
Diastolic flow reversal on spectral Doppler is caused by diastolic blood flow regurgitation and may serve as an additional bedside ultrasonography finding in individuals with severe AI. More research is needed to determine whether this Doppler finding can be used to distinguish between severe AI and arteriosclerosis in elderly people with a positive locomotor brachii sign on physical examination.
Doppler monitoring of the brachial artery in locomotor brachialis has not before been documented. Diastolic flow reversal, as well as systolic and diastolic bruit on bedside doppler tracing, is a crucial finding in determining the severity of aortic regurgitation.
Source: NEJM