Aortic Valve Regurgitation

How aortic regurgitation affects the heart

The aortic valve sits between the left ventricle and the aorta. Normally its three flaps (cusps) close tightly after each heartbeat. In aortic regurgitation, the cusps do not seal, either because they are damaged or because the aortic root has widened and pulled them apart.

Blood leaking back means the left ventricle must pump extra volume each beat. Over years it:

1. stretches and enlarges (dilates)
2. thickens to cope with the extra work
3. eventually weakens, so its pumping function falls

The changes can happen silently. That is why regular echocardiograms matter even without symptoms.

Chronic vs acute aortic regurgitation

Causes

Valve problems

• Bicuspid aortic valve: a valve with two cusps instead of three, present from birth in about 1% to 2% of people. It can leak or narrow, and is often linked to an enlarged aorta
• Endocarditis: infection that destroys the cusps. See endocarditis
• Rheumatic heart disease: after rheumatic fever, still common worldwide
• Age-related degeneration and calcification
• Some medicines in the past, such as certain appetite suppressants

Aortic root problems

• Aortic root enlargement with aging and high blood pressure
• Marfan syndrome and other connective tissue disorders
• Aortic dissection: a tear in the aortic wall, which can cause sudden severe regurgitation
• Inflammatory conditions such as ankylosing spondylitis, syphilis and giant cell arteritis

Symptoms

Many people have no symptoms for decades. When symptoms appear, they include:

• breathlessness on exertion, later at rest or lying flat
• tiredness and reduced exercise tolerance
• awareness of a strong, pounding heartbeat, especially lying on the left side
• palpitations
• chest pain, sometimes at night
• dizziness or fainting
• swelling of the ankles in advanced disease

Doctors may notice a high-pitched, blowing murmur after the second heart sound, a wide pulse pressure (high top number and low bottom number on blood pressure), and a bounding "collapsing" pulse.

Diagnosis

• Echocardiogram: the key test. It shows the valve anatomy, measures the leak and grades it as mild, moderate or severe, and measures the size and function of the left ventricle and the aorta
• Transesophageal echocardiogram: a probe in the esophagus gives clearer pictures, especially for endocarditis or planning surgery
• Cardiac MRI: precise measurement of leak volume and ventricle size
• CT angiography: measures the aorta
• ECG and chest X-ray
• Exercise testing: to check for hidden symptoms

Treatment

Monitoring

Mild and moderate regurgitation are watched with regular echocardiograms. ACC/AHA guidelines suggest intervals ranging from every 3 to 5 years for mild disease to every 6 to 12 months for severe disease without symptoms.

Medicines

• Blood pressure control, often with ACE inhibitors, ARBs or dihydropyridine calcium channel blockers, reduces strain on the heart
• Heart failure medicines for people with symptoms who are not suitable for surgery
• Beta blockers or ARBs in Marfan syndrome to slow aortic enlargement

Medicines do not fix the valve or delay surgery once surgery is indicated.

Valve surgery

Surgery is recommended for severe aortic regurgitation when:

• symptoms develop
• the left ventricle's pumping function falls (ejection fraction 55% or less)
• the left ventricle becomes significantly enlarged
• another heart operation is planned
• the aortic root is dangerously enlarged

Options:

• Surgical aortic valve replacement (SAVR) with a mechanical valve (lasts longest, needs lifelong warfarin) or a tissue valve (no long-term warfarin, wears out after 10 to 20 years)
• Valve repair in selected people, often with aortic root surgery
• Transcatheter aortic valve replacement (TAVR): mainly used for aortic stenosis. It is used in carefully selected regurgitation cases at high surgical risk

Living with aortic regurgitation

• keep all echocardiogram appointments
• control blood pressure
• report new breathlessness, chest pain or palpitations promptly
• maintain good dental hygiene and see a dentist regularly to lower endocarditis risk. Antibiotics before dental work are recommended only for people with prosthetic valves or previous endocarditis
• most people with mild to moderate disease can exercise normally. Discuss intense or heavy weight training with your cardiologist
• first-degree relatives of people with a bicuspid valve should consider an echocardiogram

Outlook

People with mild or moderate chronic aortic regurgitation often live normal lives with monitoring. Severe disease with symptoms carries a poor outlook without surgery, but valve replacement done at the right time restores near-normal life expectancy for many.

Frequently asked questions

What is aortic valve regurgitation?

It is a leak in the aortic valve that allows blood pumped into the aorta to flow back into the left ventricle. The heart has to work harder and enlarges over time. Mild leaks are common and harmless, but severe leaks need treatment.

What are the symptoms of aortic regurgitation?

Many people have no symptoms for years. Later symptoms include breathlessness on exertion or lying flat, tiredness, a pounding heartbeat, palpitations, chest pain and, in advanced cases, ankle swelling.

Is aortic regurgitation serious?

Mild and moderate regurgitation are usually not serious and are monitored. Severe regurgitation can lead to heart failure if untreated. Sudden (acute) regurgitation from infection or aortic dissection is a medical emergency.

When is valve replacement needed for aortic regurgitation?

Surgery is recommended for severe regurgitation when symptoms appear, when the left ventricle's function declines or it becomes significantly enlarged, or when the aorta is dangerously widened. Regular echocardiograms help time surgery before permanent damage.

Can aortic regurgitation get worse?

Yes. It often progresses slowly, especially with an enlarging aorta, bicuspid valve or uncontrolled blood pressure. That is why repeat echocardiograms are recommended, with frequency depending on severity.