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Aortic regurgitation

Last updated: March 5, 2021

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Aortic regurgitation (AR) is a valvular heart disease characterized by incomplete closure of the aortic valve leading to the reflux of blood from the aorta into the left ventricle (LV) during diastole. Aortic regurgitation can be acute (primarily caused by bacterial endocarditis or aortic dissection) or chronic (e.g., due to a congenital bicuspid valve or rheumatic fever) and may be caused by a valvular defect or an abnormality of the aorta. In most cases, acute AR leads to rapid deterioration of LV function with subsequent pulmonary edema and cardiac decompensation. Chronic AR may remain compensated for a long period of time, becoming symptomatic only when left heart failure develops. Auscultation reveals an S3 and a high-pitched, decrescendo early diastolic murmur. Another characteristic diagnostic finding is widened pulse pressure. Echocardiography is the most important diagnostic tool, both for confirming the diagnosis and determining the severity of disease. In asymptomatic patients, conservative treatment consists of symptom management and physical activity as tolerated. Symptomatic patients or those with severely reduced LV function require surgical intervention, most commonly aortic valve replacement.

Acute aortic regurgitation [1][2]

Chronic aortic regurgitation [1][3]

American Heart Association (AHA)/American College of Cardiology (ACC) staging system for chronic AR [5]

Staging is based on echocardiographic criteria and the presence of symptoms.

AHA/ACC staging for chronic aortic valve regurgitation [1]
Stage Definition
Stage A aortic valve regurgitation At risk of AR
Stage B aortic valve regurgitation Progressive AR Mild regurgitation
Moderate regurgitation
Stage C1 aortic valve regurgitation Asymptomatic severe AR (LVEF > 55%)
Stage C2 aortic valve regurgitation Asymptomatic severe AR (LVEF ≤ 55% or LV dilatation > 50 mm)
Stage D aortic valve regurgitation Symptomatic severe AR

References:[6][7][8]

Acute aortic regurgitation [2][9]

Signs and symptoms

Auscultation

Chronic aortic regurgitation [2]

Signs and symptoms

Auscultation

  • S3
  • High-pitched, blowing, decrescendo early diastolic murmur
    • AR due to valvular disease: heard best in the left third and fourth intercostal spaces and along the left sternal border (Erb point)
    • AR due to aortic root disease (e.g., aortic dissection): heard best along the right sternal border
    • Worsens with squatting and handgrip
  • Austin Flint murmur
    • Rumbling, low-pitched, middiastolic or presystolic murmur heard best at the apex
    • Caused by regurgitant blood striking the anterior leaflet of the mitral valve, which leads to premature closure of the mitral leaflets
  • In more severe stages, possibly a harsh, crescendo-decrescendo midsystolic murmur that resembles the ejection murmur heard in aortic stenosis
  • See also “Auscultation in valvular defects.”

Approach

Initial evaluation

Echocardiography [5][10]

Other [5]

Additional evaluation [5]

Advanced imaging

Cardiac catheterization

Exercise stress testing

  • Indication: may be used to provoke possible exertional symptoms or assess fitness in patients with severe AR
  • Findings: symptoms of aortic regurgitation (e.g., dyspnea, angina)

Approach [2][5]

  • Acute aortic regurgitation
    • Severe acute AR requires surgical treatment as soon as possible.
    • Consult cardiology and cardiothoracic surgery immediately.
    • Medical management of complications (e.g., pulmonary edema) should not delay definitive treatment.
    • Identify and treat the underlying cause (see, e.g., “Treatment” in “Infective endocarditis” and “Aortic dissection” articles).
  • Chronic aortic regurgitation
    • Surgery is the mainstay of treatment for symptomatic AR and severe asymptomatic AR.
    • Optimize medical management of comorbidities (e.g., heart failure treatment), especially if surgery is contraindicated.

All patients with acute severe aortic regurgitation should undergo urgent surgical treatment. [2]

IABP increases regurgitated volume and is contraindicated in acute severe AR. [5]

Surgical management [5]

The choice of procedure depends on the cause of the valve defect and comorbidities. All patients with severe aortic regurgitation being considered for intervention should be evaluated by members of a heart valve team if feasible.

Medical management [5]

All patients should be screened and treated for other cardiac risk factors. No medical treatments are known to influence the progression of the disease. [18]

Beta blockers may be indicated in acute AR caused by aortic dissection but should be used with caution in other causes of acute AR, as they may block compensatory tachycardia, leading to a fall in cardiac output. [5]

Monitoring [5]

  • Serial echocardiography: Regular follow-up imaging is indicated for asymptomatic patients to identify possible progression and indications for intervention.
    • Mild regurgitation (AR stage B): every 3–5 years
    • Moderate regurgitation (AR stage B): every 1–2 years
    • AR stage C1 regurgitation: every 6–12 months
    • On-demand imaging is indicated for patients with any change in signs or symptoms.
  • Asymptomatic patients with normal EF: progression to symptoms or LV dysfunction at a rate of < 6% per year
  • Asymptomatic patients with decreased EF: progression to symptoms at a rate of > 25% per year
  • Symptomatic patients: mortality rate is > 10% per year

References:[6]

  1. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2020; 143 (5). doi: 10.1161/cir.0000000000000923 . | Open in Read by QxMD
  2. Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014; 63 (22): p.e57-185. doi: 10.1016/j.jacc.2014.02.536 . | Open in Read by QxMD
  3. Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2). McGraw-Hill Education / Medical ; 2018
  4. Zipes DP. Braunwald's Heart Disease. Mosby ; 2018
  5. Curry C, Zuhlke L, Mocumbi A, Kennedy N. Acquired heart disease in low-income and middle-income countries. Archives of Disease in Childhood. 2017; 103 (1): p.73-77. doi: 10.1136/archdischild-2016-312521 . | Open in Read by QxMD
  6. Wang SS. Aortic Regurgitation. Aortic Regurgitation. New York, NY: WebMD. http://emedicine.medscape.com/article/150490-overview. Updated: February 24, 2017. Accessed: February 26, 2017.
  7. Gaasch WH. Clinical Manifestations and Diagnosis of Chronic Aortic Regurgitation in Adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-chronic-aortic-regurgitation-in-adults.Last updated: April 10, 2015. Accessed: April 9, 2017.
  8. Maurer G. Aortic regurgitation. Heart. 2006; 92 (7): p.994-1000. doi: 10.1136/hrt.2004.042614 . | Open in Read by QxMD
  9. Karen K. Stout, Edward D. Verrier. Acute Valvular Regurgitation. Circulation. 2009; 119 (25): p.3232-3241. doi: 10.1161/circulationaha.108.782292 . | Open in Read by QxMD
  10. Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for Noninvasive Evaluation of Native Valvular Regurgitation. Journal of the American Society of Echocardiography. 2017; 30 (4): p.303-371. doi: 10.1016/j.echo.2017.01.007 . | Open in Read by QxMD
  11. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease. Circulation. 2010; 121 (13): p.e266-369. doi: 10.1161/CIR.0b013e3181d4739e . | Open in Read by QxMD
  12. Pizarro R, Bazzino OO, Oberti PF, et al. Prospective Validation of the Prognostic Usefulness of B-Type Natriuretic Peptide in Asymptomatic Patients With Chronic Severe Aortic Regurgitation. Journal of the American College of Cardiology. 2011; 58 (16): p.1705-1714. doi: 10.1016/j.jacc.2011.07.016 . | Open in Read by QxMD
  13. Weber M, Hausen M, Arnold R, et al. Diagnostic and prognostic value of N-terminal pro B-type natriuretic peptide (NT-proBNP) in patients with chronic aortic regurgitation. International Journal of Cardiology. 2008; 127 (3): p.321-327. doi: 10.1016/j.ijcard.2007.07.174 . | Open in Read by QxMD
  14. Baddour LM, Wilson WR, Bayer AS, et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association. Circulation. 2015; 132 (15): p.1435-1486. doi: 10.1161/CIR.0000000000000296 . | Open in Read by QxMD
  15. Fisher ER, Stern EJ, Godwin JD, Otto CM, Johnson JA. Acute aortic dissection: typical and atypical imaging features.. Radiographics. 1994; 14 (6): p.1263-1271. doi: 10.1148/radiographics.14.6.7855340 . | Open in Read by QxMD
  16. Chawla A, Rajendran S, Yung WH, Babu SB, Peh WC. Chest radiography in acute aortic syndrome: pearls and pitfalls. Emerg Radiol. 2016; 23 (4): p.405-412. doi: 10.1007/s10140-016-1415-0 . | Open in Read by QxMD
  17. Nishimura RA et al.. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary. J Am Coll Cardiol. 2014; 63 (22): p.2438-2488. doi: 10.1016/j.jacc.2014.02.537 . | Open in Read by QxMD
  18. Flint N, Wunderlich NC, Shmueli H, Ben-Zekry S, Siegel RJ, Beigel R. Aortic Regurgitation. Current Cardiology Reports. 2019; 21 (7). doi: 10.1007/s11886-019-1144-6 . | Open in Read by QxMD
  19. Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of Rheumatic Fever and Diagnosis and Treatment of Acute Streptococcal Pharyngitis. Circulation. 2009; 119 (11): p.1541-1551. doi: 10.1161/circulationaha.109.191959 . | Open in Read by QxMD
  20. Arias EA, Bhan A, Lim ZY, et al. TAVI for Pure Native Aortic Regurgitation: Are We There Yet?. Interventional Cardiology Review. 2019; 14 (1): p.26. doi: 10.15420/icr.2018.37.1 . | Open in Read by QxMD
  21. Yoon S-H, Schmidt T, Bleiziffer S, et al. Transcatheter Aortic Valve Replacement in Pure Native Aortic Valve Regurgitation. Journal of the American College of Cardiology. 2017; 70 (22): p.2752-2763. doi: 10.1016/j.jacc.2017.10.006 . | Open in Read by QxMD
  22. Franzone A, Pilgrim T, Stortecky S, Windecker S. Evolving Indications for Transcatheter Aortic Valve Interventions. Current Cardiology Reports. 2017; 19 (11). doi: 10.1007/s11886-017-0921-3 . | Open in Read by QxMD