Aortic Regurgitation: When the Valve Leaks — What You Must Know

What is Aortic Regurgitation?

Aortic regurgitation (AR) is a valvular heart disease in which the aortic valve fails to close completely during diastole, causing blood to flow back from the aorta into the left ventricle (LV). This backflow places extra strain on the heart, leading to progressive volume and pressure overload.

According to the American Heart Association Journal, this condition can present as Acute aortic regurgitation is a medical emergency that can cause sudden pulmonary oedema, hypotension, and cardiogenic shock, whereas chronic aortic regurgitation develops gradually and leads to left ventricular dilation, systolic hypertension, and a widened pulse pressure, which develops slowly over years and results in left ventricular dilation, systolic hypertension, and a wide pulse pressure. Early recognition and timely management are essential to prevent heart failure and irreversible ventricular damage.

Causes of Aortic Regurgitation

Understanding the underlying aortic regurgitation causes is key to preventing and managing the condition effectively. The disorder may develop suddenly (acute) or gradually (chronic), depending on the root cause.

Here are the most common causes:

• Congenital bicuspid aortic valve:
  A birth defect where the aortic valve has only two flaps (cusps) instead of three, causing abnormal valve movement and leakage over time.
• Rheumatic heart disease:
  A delayed complication of untreated streptococcal throat infection, which leads to inflammation and scarring of the valve tissues, preventing proper closure.
• Infective endocarditis:
  A bacterial infection that damages the heart valve lining, leading to perforation or tissue destruction and resulting in regurgitation.
• Aortic root dilation:
  Enlargement of the aortic root due to chronic hypertension, ageing, connective tissue disorders such as Marfan syndrome, Loeys-Dietz syndrome, or Ehlers-Danlos syndrome, which prevents the valve cusps from meeting correctly.
• Chest trauma:
  A sudden blunt or penetrating injury to the chest can rupture or dislocate the aortic valve, leading to acute regurgitation.
• Degenerative (age-related) changes:
  Gradual wear and tear of the valve tissue with ageing, leading to loss of elasticity and incomplete closure of the valve.
• Autoimmune and inflammatory disorders:
  Conditions such as ankylosing spondylitis, psoriatic arthritis, systemic lupus erythematosus, or rheumatoid arthritis can cause aortitis and result in valve regurgitation, resulting in regurgitation.

Risk Factors

Several underlying conditions and lifestyle factors can increase your likelihood of developing aortic regurgitation. Understanding these risk factors helps in early detection and prevention:

• Long-standing high blood pressure:
  Chronic hypertension puts continuous strain on the aortic wall and valve, eventually leading to valve weakening and leakage.
• Connective tissue disorders (e.g., Marfan syndrome):
  Genetic conditions affecting connective tissue can cause the aortic root to enlarge, stretching the valve and preventing proper closure.
• Congenital heart defects:
  Being born with a malformed aortic valve, such as a bicuspid valve, predisposes individuals to regurgitation later in life.
• Age above 60 years:
  With ageing, natural wear and calcification of the aortic valve can impair its function, increasing the risk of regurgitation.
• History of infective endocarditis:
  Prior infection of the heart valves can leave scar tissue or structural damage, leading to chronic valve leakage.
• Previous aortic valve surgery:
  Surgical repair or replacement can sometimes alter valve dynamics or weaken the surrounding tissue, predisposing patients to recurrent aortic regurgitation.

Signs & Symptoms of Aortic Regurgitation

In its early stages, aortic regurgitation may progress silently, as the heart compensates for the backward flow of blood. Many people remain symptom-free for years. However, as the condition worsens and the heart becomes strained, noticeable symptoms begin to appear.

Common aortic regurgitation symptoms include:

• Fatigue and weakness:
  Reduced forward blood flow from the heart decreases oxygen delivery to muscles, leading to tiredness - especially during physical activity.
• Shortness of breath (dyspnoea):
  Initially felt during exertion and later even at rest, due to fluid build-up in the lungs from increased pressure in the left ventricle.
• Palpitations or awareness of heartbeat:
  A forceful or irregular heartbeat, especially when lying down, is common as the heart tries to compensate for regurgitant blood flow.
• Swelling in ankles or feet (oedema):
  This results from fluid retention as heart efficiency declines over time.
• Left chest pain:
  May occur due to increased cardiac workload or reduced coronary perfusion during diastole in chronic severe AR.
• Lightheadedness or fainting:
  Due to a sudden drop in blood pressure or reduced blood flow to the brain.
• Rapid or irregular pulse:
  Caused by changes in blood volume and heart rhythm as the left ventricle dilates.
• Heart murmur:
  A classic sign of aortic regurgitation — a distinctive whooshing sound heard through a stethoscope during diastole, indicating backward blood flow.

How Aortic Regurgitation is Diagnosed

Diagnosing aortic regurgitation involves a combination of clinical evaluation, imaging, and specialised cardiac tests. The process helps determine the severity of valve leakage, its underlying cause, and the best course of treatment.

Here’s a step-by-step overview of the aortic regurgitation diagnosis process:

Step 1: Detailed medical history and physical examination
Your doctor begins by reviewing your symptoms, medical history, and risk factors. During the physical exam, they listen to the heart using a stethoscope to detect a characteristic heart murmur, often described as a “blowing” sound during diastole.

Step 2: Echocardiogram (ECHO)
This is the key diagnostic test. It uses ultrasound waves to visualise the aortic valve, measure blood flow, and assess how much blood leaks back into the left ventricle. Both transthoracic (TTE) and transoesophageal (TEE) echocardiograms may be used.

Step 3: Electrocardiogram (ECG)
An ECG records the heart’s electrical activity, helping detect arrhythmias, heart enlargement, or strain on the left ventricle caused by chronic regurgitation.

Step 4: Chest X-ray
This imaging test can reveal heart enlargement or signs of fluid buildup in the lungs, common in long-standing aortic regurgitation.

Step 5: Cardiac MRI or CT Scan
These advanced imaging tests provide detailed 3D views of the heart, aorta, and valve anatomy. They are especially useful for evaluating aortic root dilation and surgical planning.

Step 6: Cardiac Catheterisation
Performed when surgery is being considered, this invasive test measures pressures inside the heart chambers and evaluates coronary artery health before valve replacement or repair.

Tests to Diagnose Aortic Regurgitation

To confirm the presence and severity of aortic regurgitation, your doctor may recommend a combination of imaging and laboratory tests. These help assess heart structure, function, and any associated complications.

Here are the key tests used for aortic regurgitation diagnosis:

• 2D/3D Echocardiography:
  The primary diagnostic test for aortic regurgitation, providing real-time assessment of valve structure, regurgitant volume, and left ventricular size and function. It provides real-time images of the heart and aortic valve, helping measure the extent of backflow and assess left ventricular function.
• Doppler Studies:
  Often combined with echocardiography, Doppler imaging measures the direction and velocity of blood flow, quantifying the regurgitant volume and pressure gradient across the valve.
• Electrocardiogram (ECG):
  Records the electrical activity of the heart to detect rhythm abnormalities, left ventricular hypertrophy, or strain caused by chronic leakage.
• Chest X-ray:
  Helps visualise heart enlargement and check for signs of pulmonary congestion or fluid accumulation in the lungs.
• Cardiac MRI:
  Provides detailed, high-resolution images of the heart and aorta. It is particularly useful for assessing aortic root dilation and left ventricular remodelling.
• Blood Tests:
  Measurement of BNP or NT-proBNP levels assists in assessing heart failure severity and ventricular strain, complementing imaging findings, while infection screening can detect infective endocarditis, a common cause of acute regurgitation.

Complications of Untreated Aortic Regurgitation

If aortic regurgitation is left undiagnosed or untreated, the persistent backflow of blood into the left ventricle can progressively damage the heart and lead to life-threatening complications. Early detection and timely management are therefore crucial.

Major complications include:

• Left Ventricular Failure:
  Continuous volume overload causes the left ventricle to enlarge and weaken, reducing its ability to pump blood effectively — a key sign of advanced heart failure.
• Pulmonary Hypertension:
  Chronic elevation of left ventricular filling pressures can lead to pulmonary venous congestion and secondary pulmonary hypertension, worsening breathlessness and straining the right side of the heart.
• Arrhythmias (Irregular Heart Rhythms):
  Stretching of the heart chambers can disrupt electrical activity, leading to atrial fibrillation or ventricular tachycardia, which increases stroke and cardiac arrest risk.
• Cardiomegaly (Enlarged Heart):
  The left ventricle expands to handle extra blood volume, but over time, this compensatory mechanism leads to muscle thickening, stiffness, and reduced efficiency.
• Endocarditis Recurrence:
  Damaged or prosthetic valves make the heart more vulnerable to recurrent bacterial infections, worsening regurgitation and causing further tissue destruction.
• Sudden Cardiac Arrest:
  Severe, uncorrected aortic regurgitation can trigger fatal rhythm disturbances or abrupt heart failure, particularly during physical exertion.

Treatment Options for Aortic Regurgitation

The aortic regurgitation treatment strategy depends on how severe the leakage is and how well the heart is functioning. In mild or early-stage cases, careful monitoring and medication may suffice, while advanced or symptomatic cases often require surgical correction.

1. Medications

Drugs do not cure the structural problem but can help manage symptoms and delay disease progression until surgery becomes necessary.

Commonly used medicines include:

• Vasodilators (ACE inhibitors, ARBs):
  Help reduce blood pressure and ease the workload on the heart by widening blood vessels.
• Diuretics:
  Help the body eliminate excess fluid, reducing swelling and relieving shortness of breath.
• Beta-blockers:
  Used cautiously in chronic AR; they may worsen regurgitation by prolonging diastole but are beneficial in aortic root dilation syndromes such as Marfan or Loeys-Dietz.
• Antibiotic prophylaxis:

Recommended only for individuals with prosthetic heart valves, prior infective endocarditis, or certain congenital heart conditions before dental or invasive procedures.

2. Surgical Intervention

When aortic regurgitation becomes severe or causes significant symptoms, surgery is the most effective treatment option. The primary procedure is Aortic Valve Replacement (AVR).

• Mechanical Valve Replacement:
  Involves implanting a durable prosthetic valve, ideal for younger patients, requiring lifelong anticoagulation with warfarin to prevent thromboembolism, though it requires lifelong anticoagulant therapy to prevent blood clots.
• Biological (Tissue) Valve Replacement:
  Made from animal (porcine or bovine) or human donor tissue; does not require long-term anticoagulation but has limited durability, typically lasting 10–20 years. These valves don’t require long-term anticoagulation and are preferred for older adults or those unable to take blood thinners.
• Aortic Root Surgery:
  Recommended when the aortic root (the section of the aorta attached to the valve) is dilated or weakened, ensuring the entire valve complex is properly supported.

3. Lifestyle and Monitoring

Even after treatment, lifestyle modifications and regular check ups play a key role in managing aortic regurgitation:

• Schedule routine cardiac evaluations and echocardiograms to track valve function.
• Maintain optimal blood pressure and cholesterol levels through diet and prescribed medication.
• Limit salt intake and completely avoid smoking or excessive alcohol consumption.
• Engage in regular, cardiologist-approved aerobic activity; avoid heavy weightlifting or high-intensity exertion that can raise aortic wall stress.
• Manage chronic conditions such as diabetes or hypertension carefully, as they can worsen heart health.

Prevention and Early Detection

While not all cases can be prevented, several measures can lower the risk or help detect the disease early:

• Promptly treat strep throat to prevent rheumatic fever and subsequent valve damage.
• Control high blood pressure to reduce strain on the aortic wall and valve.
• Get routine echocardiograms if you have congenital valve abnormalities or a family history of valve disease.
• Maintain excellent oral hygiene to minimise bacteria that could cause infective endocarditis.
• Seek medical evaluation for any heart murmur, fatigue, or breathlessness, even if mild.

Conclusion

Aortic regurgitation is a serious but manageable heart valve condition. With early diagnosis through echocardiography, timely medical management, and surgical correction when required, patients can significantly improve their survival and quality of life. Recognising early aortic regurgitation symptoms—such as shortness of breath, fatigue, or left chest pain—and seeking prompt medical attention can prevent complications like heart enlargement or failure.

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FAQs

What is the difference between mild, moderate, and severe aortic regurgitation?

Mild AR causes minimal backflow and may not produce symptoms. Moderate AR increases heart workload, while severe AR leads to significant blood leakage, heart enlargement, and failure if untreated.

Can aortic regurgitation be cured without surgery?

No. While medications can ease symptoms, only surgery or valve replacement can correct structural valve defects.

What are the first signs of aortic regurgitation?

Early signs often include fatigue, mild shortness of breath, or a detectable heart murmur during routine check-ups.

How often should I be monitored if I have aortic regurgitation?

Mild aortic regurgitation– once every 1–2 years.
Moderate aortic regurgitation– every 6–12 months.
Severe aortic regurgitation– every 3–6 months or as recommended by your cardiologist.

Can lifestyle changes help manage aortic regurgitation?

Yes. Regular physical activity, a balanced diet, blood pressure control, and routine follow-ups can slow disease progression and improve heart function.