SamDawkins Consultant Cardiologist

Aortic Regurgitation

Aortic regurgitation is a leaking aortic valve. The aortic valve sits between the left ventricle and the aorta, and normally prevents blood flowing backwards once the heart has finished pumping. In aortic regurgitation the valve does not close properly, so blood leaks backwards into the left ventricle with every beat. Over time this volume overload causes the left ventricle to dilate and weaken.

What causes aortic regurgitation?

There are two broad mechanisms — a problem with the aortic valve leaflets themselves, or a problem with the aortic root that they are anchored to.

  • Degenerative leaflet disease — wear and tear of the leaflets in older patients.
  • Bicuspid aortic valve — a common congenital variation where the valve has two leaflets rather than three. Bicuspid valves often leak earlier than tricuspid valves and are frequently associated with a dilated aortic root.
  • Aortic root dilatation — when the root stretches, the leaflets no longer meet in the middle. Causes include connective tissue conditions (Marfan syndrome, Loeys-Dietz), bicuspid-related root disease, and isolated annulo-aortic ectasia.
  • Endocarditis — infection of the valve, which can rapidly destroy a leaflet and produce acute severe regurgitation.
  • Aortic dissection — a tear in the wall of the aorta, which can disrupt the valve and present as an emergency.
  • Rheumatic disease — uncommon in the UK now, but a major cause worldwide.

What are the symptoms?

Mild and moderate aortic regurgitation rarely cause symptoms. As the leak becomes severe, patients may develop:

  • Breathlessness on exertion
  • Reduced exercise tolerance
  • Palpitations or an awareness of a forceful, bounding heartbeat
  • Fatigue
  • Symptoms of heart failure if the left ventricle starts to fail

Acute severe aortic regurgitation — for example from endocarditis or dissection — is a medical emergency presenting with sudden severe breathlessness and shock.

How is aortic regurgitation assessed?

The diagnosis is usually made on echocardiography, supported by additional imaging where intervention is being considered.

  • Electrocardiogram (ECG) — looks for left ventricular hypertrophy and rhythm disturbances.
  • Transthoracic echocardiogram (TTE) — the principal test. Grades the severity, assesses left ventricular size and function, and shows the aortic root.
  • Transoesophageal echocardiogram (TOE) — high-resolution images, particularly of the leaflets and the root, when intervention is being planned.
  • Cardiac MRI — the gold standard for quantifying the regurgitant volume and left ventricular size, particularly when echo findings are equivocal.
  • Cardiac CT — for detailed assessment of the aortic root and procedural planning when transcatheter intervention is being considered.
  • Stress echocardiography — used in selected patients to clarify the haemodynamic significance.
  • Blood tests — kidney function, BNP, full blood count.

What are the treatment options?

Mild and moderate aortic regurgitation are managed with medication and observation. Once the leak becomes severe, with symptoms or evidence of impact on the left ventricle, treatment should be considered.

  • Open-heart surgery — the gold standard for severe symptomatic aortic regurgitation. Either valve replacement (with a tissue or mechanical valve), or — in selected patients with leaflet prolapse and a normal root — repair. Where the root is dilated, a combined valve and root procedure may be performed.
  • TAVI for aortic regurgitation — transcatheter aortic valve implantation using a dedicated AR device (JenaValve or J-Valve), for patients at increased risk for surgery. Conventional TAVI valves rely on calcium for anchoring and are not generally suitable for pure AR; the dedicated AR devices grip the native leaflets to lock the new valve in place.
  • Medical therapy alone — for patients in whom intervention is not appropriate.

The right choice depends on the underlying mechanism, the severity of the leak, the function of the left ventricle, surgical risk, and the dominant symptoms. The decision is always made in a structural valve multidisciplinary team meeting.