Holman's Sign in Aortic Regurgitation

Definition and Diagnostic Significance

• Holman's sign refers to holodiastolic flow reversal in the proximal abdominal aorta detected on echocardiography, indicating retrograde blood flow from the aorta into the left ventricle during diastole, according to the American College of Cardiology 1
• This sign is one of the established markers of severe aortic regurgitation (AR) according to multiple clinical practice guidelines, including the European Heart Journal 1, 2
• The presence of this sign helps differentiate severe AR from mild or moderate AR, as it indicates a significant regurgitant volume, as stated by the European Heart Journal 2

Clinical Significance in Severity Assessment

• Holman's sign is part of a multi-parametric approach to assess AR severity, alongside other echocardiographic parameters including vena contracta width >0.6 cm, regurgitant volume ≥60 mL/beat, regurgitant fraction ≥50%, and effective regurgitant orifice area (EROA) ≥0.3 cm², as recommended by the European Heart Journal 2
• The American College of Cardiology suggests that the presence of Holman's sign, in combination with other parameters, helps clinicians identify patients who may require closer monitoring or intervention, as severe AR is associated with significant morbidity and mortality 1, 3

Implications for Patient Management

• Detection of Holman's sign should prompt comprehensive assessment of left ventricular size and function, as severe AR leads to progressive LV dilation and potential systolic dysfunction, according to the American College of Cardiology 3
• In patients with severe AR indicated by Holman's sign and other parameters, asymptomatic patients with normal LV function require surveillance echocardiography every 6-12 months, as recommended by the European Heart Journal 2
• Symptomatic patients with severe AR should be referred for surgical intervention regardless of LV function, as stated by the American College of Cardiology 3

Differential Diagnostic Value

• Holman's sign helps distinguish acute from chronic AR, with the sign being present despite normal or only mildly increased LV dimensions in acute AR, and typically accompanied by LV dilation and other compensatory changes in chronic AR, as described by the European Heart Journal 4

Pitfalls and Caveats

• Holman's sign should not be used in isolation for AR severity assessment but as part of a comprehensive evaluation, as recommended by the European Heart Journal 2
• Technical factors can affect detection, including suboptimal Doppler alignment and respiratory variations, as noted by the European Heart Journal 4
• In patients with aortic dissection and concomitant AR, Holman's sign may be present due to the AR component, requiring careful differentiation of the primary pathology, as stated by the European Heart Journal 5

Relation to Acute Aortic Syndromes

• In the context of acute aortic syndromes, the presence of Holman's sign may indicate aortic regurgitation as a complication of aortic dissection, according to the European Heart Journal 5
• When AR is detected in the setting of suspected aortic dissection, immediate surgical intervention is typically required, as this represents a surgical emergency, as stated by the American College of Cardiology 3