What Is It, Causes, Diagnosis, Treatment, and More
Author:Michail Mavrogiannis, MD
Editors:Alyssa Haag,Ian Mannarino, MD, MBA
Copyeditor:Sadia Zaman, MBBS, Bsc
What is aortic regurgitation?
Aortic regurgitation, or aortic insufficiency, is a condition in which there is inadequate closure of the aortic valve during cardiac diastole, leading to the leakage of blood from the aorta into the left ventricle. As a result, there is reverse blood flow through the aortic valve.
The aortic valve is typically made up of three leaflets and opens widely during systole to allow the ejection of blood, which is pumped from the left ventricle through the aorta to the rest of the body. During diastole, the aortic valve closes to allow the heart to fill with blood and prepare for the subsequent systole. If the valve doesn’t close completely, blood leaks back into the left ventricle, and aortic regurgitation occurs.
Is aortic regurgitation common?
Aortic regurgitation is a relatively common condition, affecting around 5 to 10 percent of the population. It occurs more commonly in individuals who are assigned male at birth. The prevalence of aortic regurgitation increases with age, and it occurs most often in individuals older than 50 years of age.
What causes aortic regurgitation?
Aortic regurgitation is caused by issues with the supporting structures of the aortic root (e.g., aortic root dilation) or inadequate closure of the aortic valve leaflets during diastole. This can be either due to an impairment of the leaflets, or an increased afterload, which is the resistance that the heart needs to overcome in order to open the aortic valve.
The most common cause of aortic regurgitation is aortic root dilation, in which the first part of the aorta leaving from the heart (i.e. aortic root) becomes enlarged. It mainly occurs as a result of aging. Other causes of aortic root dilation include various conditions, such as Behcet’s disease, reactive arthritis, Marfan syndrome, osteogenesis imperfecta, syphilitic aortitis, and aortic dissection. A common cause of leaflet impairment that can lead to aortic regurgitation includes aortic valve calcification. Aortic valve calcification can either result from normal aging, or can be caused by congenital conditions, such as a bicuspid aortic valve, which can accelerate calcification. Other causes of leaflet impairment include infectious diseases, such as bacterial endocarditis (i.e., infective endocarditis), and rheumatic fever; inflammatory disorders such as systemic lupus erythematosus (SLE) and rheumatoid arthritis; and traumatic injury. High blood pressure, or hypertension, supravalvular aortic stenosis, and coarctation of the aorta (i.e., narrowing in the aorta) can also lead to aortic regurgitation by increasing the afterload.
What are the signs and symptoms of aortic regurgitation?
In the early stages of the condition, individuals with aortic regurgitation are typically asymptomatic. As aortic regurgitation develops gradually, symptoms may take years or even decades to manifest. When they do occur, symptoms include exertional dyspnea (i.e., shortness of breath upon exercise), orthopnea, (i.e., shortness of breath upon lying), paroxysmal nocturnal dyspnea (i.e., shortness of breath at night when the heart rate slows down), angina (i.e., chest pain), peripheral edema (i.e., swollen ankles and feet), fainting, a characteristic heart murmur, and palpitations. Sometimes, aortic regurgitation can occur acutely, typically as a result of an infection of the aortic valve, or pulmonary edema, where excess fluid is gathered in the lungs. Both can present with tachycardia (i.e., an increased heart rate) and tachypnea (i.e., an increased respiratory rate).
Clinical signs, also called peripheral signs of severe aortic regurgitation, are associated with the increase in the pulse pressure (approximately proportional to stroke volume), which is the difference between the systolic and diastolic blood pressures. As the blood regurgitates back into the left ventricle during diastole, the diastolic pressure in the aorta decreases, thereby leading to an increase in the pulse pressure. Additionally, the systolic blood pressure is often increased to compensate for the reduction in diastolic pressure, in an attempt to drive the forward flow of blood, which further widens the pulse pressure. Clinical signs of aortic regurgitation include the Becker sign, which is the visible pulsation of retinal arterioles via an ophthalmoscope; Corrigan pulse, which is a fast and forceful distension of the arterial pulse that collapses quickly; de Musset sign, which is when the head bobs with each heartbeat; Muller sign, which is the visible pulsation of the uvula; Quincke sign, which is the visible capillary pulsation at the root of the nail; Duroziez sign, which is a systolic and diastolic bruit (i.e., a sound that is heard when there is turbulence in the flow of blood) heard over the femoral artery when compressed; and Traube sign, which is a booming sound heard over the femoral artery. Other clinical signs include the Gerhardt sign, which is the detectable pulsations of the spleen in the presence of splenomegaly; Hill sign, where the blood pressure of the legs is greater than the blood pressure of the upper extremities; Rosenbach sign, which is the pulsation of the liver; Mayne sign, which is the drop in diastolic pressure of 15mm Hg upon the raising of the upper extremity above the head; and Landolfi sign, which when the pupil contracts during diastole and dilates during diastole. Finally, on auscultation by a healthcare provider, aortic regurgitation can be identified as a soft, high-pitched, early diastolic decrescendo murmur.
How is aortic regurgitation diagnosed?
Aortic regurgitation is typically diagnosed after a thorough medical history review of relevant signs and symptoms. The key diagnostic tool for diagnosing the cause and severity of aortic regurgitation is echocardiography, or an ultrasound of the heart. Findings from the echocardiography may include dilation of the left ventricle, which is commonly seen in chronic aortic regurgitation; adequate systolic function until the later stages of the condition; and a decreased ejection fraction (EF), which is the percentage of blood leaving the left ventricle in each systole. A chest x-ray may also help establish the diagnosis and may show an enlarged heart due to the enlargement of the left ventricle. An EKG, or electrocardiogram, may indicate hypertrophy, or increases in the size of the heart muscle cells, of the left ventricle. Other imaging modalities, such as Cardiac Magnetic Resonance (CMR), are useful in cases where echocardiography is not sufficient. Pulmonary artery catheterization, which is more invasive, may also help establish the severity of the condition.
How is aortic regurgitation treated?
Management of patients with aortic regurgitation depends on the signs and symptoms of the disease, the degree of the left ventricular dysfunction, and the duration of the disease (i.e., acute or chronic). Individuals with mild disease usually do not need treatment and may be monitored annually to assess the progression of aortic regurgitation. Antibiotics might be administered to prevent infection. Asymptomatic individuals can receive surgical treatment if the EF is low or if there is severe left ventricular dilatation. Individuals with mild to severe aortic regurgitation who experience relevant symptoms, or show an abnormal response to exercise testing, usually undergo surgery. Surgical treatment, which involves aortic valve replacement (AVR) is the definitive treatment of aortic regurgitation. Medical treatment, which aims at reducing the afterload and relieving symptoms, can also be used and often includes ACE inhibitors, such as ramipril, and calcium channel blockers, such as amlodipine.
For individuals with acute aortic regurgitation emergencies, surgical treatment with aortic valve replacement is recommended to prevent life-threatening complications. Medications may also be used to stabilize the individual until surgery is performed.
Is aortic regurgitation serious?
Aortic regurgitation can be a fairly serious condition. Individuals with mild to severe disease who experience symptoms usually undergo surgical treatment. If aortic regurgitation is left untreated, congestive heart failure can occur, which is a life-threatening condition that occurs due to the inability of the heart to pump blood properly to the rest of the body.
What are the most important facts to know about aortic regurgitation?
Aortic regurgitation, or aortic insufficiency, is a relatively common and serious condition in which there is inadequate closure of the aortic valve during diastole, causing reverse blood flow through the aortic valve and leakage of blood from the aorta into the left ventricle. The most common cause of aortic regurgitation is aortic root dilation, which is most commonly the result of aging. Leaflet impairment, which can either result from normal aging or congenital conditions such as bicuspid aortic valve, can also cause aortic regurgitation. Other causes include hypertension, which can lead to aortic regurgitation by increasing the afterload. The key tool for diagnosing aortic regurgitation, its cause, and its severity, irrespective of the presence of symptoms is echocardiography. Management of patients with aortic regurgitation depends on the signs and symptoms of the disease, the degree of the left ventricular dysfunction, and the duration of the disease. Aortic valve replacement (AVR) is the definitive treatment of aortic regurgitation for individuals who require treatment.
Watch related videos:
Related linksIntroduction to the cardiovascular system
Anatomy of the heart
Aortic valve disease
Valvular heart disease: Clinical practice
Resources for research and reference
Bonow, R. O., Libby, P., Mann, D. L., Gordon, F. T., & Zipes, D. P. (2018). In: Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. Amsterdam, Netherlands: Elsevier.
Dewaswala, N., & Chait, R. Aortic Regurgitation. [2021, Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing LLC. Retrieved August 19, 2021 from: https://www.ncbi.nlm.nih.gov/books/NBK555944/
Healio. (2018). Aortic Regurgitation Topic Review. In: Healio. Retrieved August 19, 2021 from: https://www.healio.com/cardiology/learn-the-heart/cardiology-review/topic-reviews/aortic-regurgitationMaurer, G. (2006). Aortic regurgitation. Heart (British Cardiac Society), 92(7), 994–1000. DOI: 10.1136/hrt.2004.042614