Aortic regurgitation is a condition in which blood leaks back through the aortic valve. This is because the valve does not close properly. With each heartbeat, more blood than usual enters the left ventricle and so it needs to work harder. Mild regurgitation may not cause symptoms. More severe regurgitation can cause symptoms and may lead to heart failure. Medication can help to ease symptoms. Surgery to replace the valve may be needed.
Understanding the heart
The heart has four chambers - two atria and two ventricles. The walls of these chambers are mainly made of special heart muscle. During each heartbeat both of the atria squeeze (contract) first to pump blood into the ventricles. Then both ventricles contract to pump blood out of the heart into the arteries. There are one-way valves between the atria and ventricles, and between the ventricles and the large arteries coming from the heart. The valves make sure that when the atria or ventricles contract, the blood flows in the correct direction.
What is the aortic valve and what is aortic regurgitation?
The aortic valve lies between the left ventricle and the aorta. When the left ventricle relaxes, the aortic valve closes and the mitral valve opens. This allows more blood into the ventricle, ready for the next heartbeat.
Aortic regurgitation is sometimes called aortic incompetence or a leaky aortic valve. In aortic regurgitation the valve does not close properly. Therefore, blood leaks back (regurgitates) into the left ventricle from the aorta.
In some cases, aortic regurgitation occurs at the same time as aortic stenosis. See separate leaflet called Aortic Stenosis.
What are the causes of aortic regurgitation?
The main causes include the following:
Rheumatic fever is a condition that sometimes occurs during an infection with a germ (bacterium) called the streptococcus. Your body makes antibodies to the bacterium to clear the infection. However, in some people the antibodies also attack various parts of the body, in particular the heart valves. Inflammation of a valve may develop which can cause permanent damage and lead to thickening and scarring years later.
Abnormal widening of the base of the aorta
If the root of the aorta becomes abnormally wide, the cusps of the valve cannot meet and the valve becomes leaky. The tissue at the base of the aorta can be affected by various conditions such as: Marfan's syndrome, ankylosing spondylitis, rheumatoid arthritis, reactive arthritis, relapsing polychondritis (an inflammatory condition of the cartilage tissue of the body), syphilis.
- Congenital causes. (A congenital condition is a condition that is present from birth.) Various heart problems which may be present at birth may include aortic regurgitation.
- Infection of the valve (endocarditis). See separate leaflet called Infective Endocarditis.
What are the symptoms of aortic regurgitation?
- If the leak is small you are not likely to have any symptoms.
- If the backflow of blood becomes worse the left ventricle has to work harder with each heartbeat to pump the extra blood back into the aorta. The wall of the ventricle may then enlarge and may also become thickened (hypertrophied). Symptoms can then include:
- Chest pain (angina) when you exert yourself. This occurs because of reduced blood flow to the coronary arteries.
- Forceful heartbeats which you may feel as the sensation of having a 'thumping heart' (palpitations).
- If the backflow of blood is severe the left ventricle may not function properly and you can develop heart failure. This causes shortness of breath, tiredness and fluid retention in various tissues of the body.
What are the possible complications of aortic regurgitation?
- Heart failure may become severe and life-threatening. See separate leaflet called Heart Failure.
- Infection of the valve (endocarditis) is an uncommon complication. (Abnormal valves are more prone than normal valves to infection.) Unless promptly treated, endocarditis can cause serious illness.
How is aortic regurgitation diagnosed?
- A doctor may hear a heart murmur or other abnormal noises when listening with a stethoscope. Murmurs and noises are due to blood passing through abnormal valves, or to abnormal movement of valves. There are typical murmurs and noises which occur with aortic regurgitation. Sometimes this is detected on a routine examination if you have no symptoms, and the regurgitation is mild.
- A heart tracing (an electrocardiogram, or ECG) can show that the left ventricle is thickened or enlarged.
- An ultrasound scan of the heart (echocardiogram) can confirm the diagnosis.
What are the treatments for aortic regurgitation?
If the backflow of blood is mild and you have no symptoms then you may not need any treatment. If you develop symptoms or complications, various medicines may be advised to ease the symptoms. Surgery may be advised if symptoms become worse.
Medication may be advised to help ease symptoms of heart failure if heart failure develops. For example:
- 'Water' tablets (diuretics) usually help if you are breathless. They make the kidneys produce more urine. This gets rid of excess blood and fluid which may build up in the lungs or other parts of the body with heart failure.
- Angiotensin-converting enzyme (ACE) inhibitors are medicines which help to reduce the amount of work the heart does and to ease symptoms of heart failure.
Surgical options include repair of the aortic valve or replacement of the valve. The most recent guideline recommends replacement as the preferred option in most cases. Valve replacement surgery may be with a mechanical or a tissue valve. Mechanical valves are made of materials which are not likely to react with your body, such as titanium. Tissue valves are made from treated animal tissue, such as valves from a pig. If you need surgery, a surgeon will advise on which is the best option for your situation.
Surgical treatment has greatly improved the outlook in most people with more severe regurgitation. The outlook (prognosis) is good if the valve is treated before the heart becomes badly damaged.
Antibiotics to prevent endocarditis
Antibiotics used to be offered to all people with heart valve disease before dental treatment and some surgical procedures to prevent the development of infection of the valve (endocarditis). However, the National Institute for Health and Care Excellence (NICE) issued guidance in 2008 which advised that people at risk of endocarditis only need to take antibiotics if they actually have an infection at the time that dental or surgical procedures are undertaken. This guidance has been criticised by other authorities and antibiotics are still sometimes given to patients at the highest risk of endocarditis.
Good oral hygiene and dental hygiene are also thought to be important in helping to prevent infective endocarditis. In particular, if you have any condition which increases your risk of developing infective endocarditis (see above), you should not let any dental problems such as a dental abscess or gum disease go untreated. These dental conditions increase the chance of germs (bacteria) getting into the bloodstream.
What is the outcome?
The outcome (prognosis) will depend on the underlying cause and the severity of aortic regurgitation. The outcome is generally poor if there is no treatment but is good with available modern treatments.
Further reading & references
- Prophylaxis against infective endocarditis: Antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures; NICE Clinical Guideline (March 2008)
- Nishimura RA, Otto CM, Bonow RO, et al; 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease. Circulation. 2017; CIR.0000000000000503. Originally published March 15, 2017.
- Vahanian A et al; Guidelines on the management of valvular heart disease: The Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology, 2017.
- Tourmousoglou C, Lalos S, Dougenis D; Is aortic valve repair or replacement with a bioprosthetic valve the best option for a patient with severe aortic regurgitation? Interact Cardiovasc Thorac Surg. 2014 Feb;18(2):211-8. doi: 10.1093/icvts/ivt453. Epub 2013 Nov 7.
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. Patient Platform Limited has used all reasonable care in compiling the information but makes no warranty as to its accuracy. Consult a doctor or other healthcare professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Laurence Knott
Dr Jacqueline Payne