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Aortic regurgitation is the regurgitation (back flow) of blood to the
left ventricle of the heart during diastole (relaxation) due aortic
As the left ventricle relaxes to fill with blood from the left
atrium, blood leaks backward from the aorta, increasing the volume and
pressure of blood in the left ventricle. As a result, the amount of work
the heart has to do increases. To compensate, the muscular walls of the
ventricles hypertrophy, and the chambers of the ventricles dilate.
Eventually, despite this compensation, the heart may be unable to meet
the body's need for blood, leading to heart failure.
Aortic insufficiency affects approximately 5 out of
every 10,000 people.
Generally more common in men
It is most common in men between the ages of 30 and
60. However, women and those older or younger can be affected too.
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Causes and risk factors
Rheumatic fever and syphilis used to be the most common causes of
aortic regurgitation in North America, Australasia, and Western Europe,
where both disorders are now rare because of the widespread use of
antibiotics. In regions in which antibiotics are not widely used, aortic
regurgitation due to rheumatic fever or syphilis is still common.
Aside from these infections, the most common causes of severe aortic
regurgitation are weakening of the valve's usually tough, fibrous tissue
due to myxomatous degeneration (a hereditary disorder in which the valve
gradually becomes floppy); degeneration of the valve due to unknown
factors; aortic aneurysms; and aortic dissection.
Common causes of mild aortic regurgitation are severe high blood
pressure and a birth defect in which the aortic valve consists of two
cusps (bicuspid valve) instead of the usual three (tricuspid valve).
About 2% of boys and 1% of girls are born with this defect. Other causes
of aortic regurgitation include bacterial infection of a heart valve
(infective endocarditis) and injury.
Basically, any condition that damages a valve can cause or predispose
regurgitation. Some of the more common ones include:
- Ankylosing spondylitis, a spinal disorder
- Aortic dissection and aortic aneurysm
- Congenital heart defects that are present at birth, such as
unicuspid or bicuspid aortic valve
- High blood pressure
- Infective endocarditis, an infection in the valves or lining of
- Marfan syndrome, an inherited disease of connective tissues
- Reiter syndrome, an arthritic disorder that affects adult males,
which is now rare
- Rheumatic fever, a disease that can cause arthritis and heart
- Rheumatoid arthritis, which also causes joint pain and swelling
- Syphilis, especially congenital syphilis
- Systemic lupus erythematosus, an autoimmune disorder in which
the person creates antibodies against his or her own tissues
- Ehlers - Danlos syndrome
- Pseudoxanthoma elasticum
- Deterioration of the valve with age
The ventricles pump blood in a forward direction from the heart to
the aorta. Normally the aortic valve prevents backflow of blood to the
heart when the heart relaxes after pumping. Back flow of the blood to
the ventricle during relaxation leads to a subsequent increase in left
ventricular volume. This leads to an increase in systolic blood pressure
which is accompanied by reflex peripheral vessel dilatation which lowers
the diastolic blood pressure resulting in a wide pulse pressure. The
lowering of the diastolic blood pressure reduces flow of blood to the
coronaries which relies on diastolic pressure. The resultant volume
overload eventually leads to heart failure.
A leak may develop gradually (over months or years) or quickly (over
hours or days). Aortic regurgitation may result when the aorta enlarges,
often because of high blood pressure. When the aorta is enlarged, the
valve may not close completely. As a result, blood leaks backward
through the valve into the heart.
Aortic regurgitation may worsen if a person has a heart infection or
aortic dissection. The function of the left heart chamber may
deteriorate quickly within a few weeks or months. Chronic regurgitation
usually progresses slowly. It can cause severe congestive heart failure,
Most often aortic valve regurgitation develops gradually, and the
heart compensates for the problem. Aortic regurgitation usually
progresses slowly over years. Mild aortic regurgitation produces no
symptoms other than a characteristic heart murmur on auscultation. Many
people do well despite moderate to severe regurgitation of the aortic
valve. However, as aortic valve regurgitation progresses, signs and
symptoms usually appear and may include:
Fatigue and weakness, especially when the
activity level is increased
Shortness of breath, especially with exertion
or when lying flat
Angina pectoris ? about 5% chest pain,
discomfort or tightness, often increasing during exercise
Rapid or irregular pulse
Edema that shows as swollen ankles and feet
The physical examination of an individual with aortic insufficiency
involves auscultation of the heart to listen for the murmur of aortic
insufficiency and related heart sounds. The murmur of chronic aortic
insufficiency is a holodiastolic (lasts all of diastole) decrescendo
murmur (starts off loud and becomes soft). The murmur of chronic aortic
insufficiency has the following characteristics:
- Systolic ejection click
- Ejection murmur
- S3 present
- Holodiastolic decrescendo murmur - best heard with patient
sitting and leaning forward (If radiation to the right parasternal
region, consider ascending aortic aneurysm)
- Austin flint murmur (an apical diastolic rumble due to mitral
Physical signs of aortic insufficiency are related to the wide pulse
pressure and the rapid decrease in blood pressure during diastole due to
- Lighthouse sign (blanching & flushing of forehead)
- de Musset's sign (head nodding in time with the heart beat)
- Ladolfi's sign (alternating constriction & dilatation of pupil)
- Becker's sign (pulsations of retinal vessels)
- M?ler's sign (pulsations of uvula)
- Corrigan's pulse (rapid upstroke and collapse of the carotid
- (Watson's) Water-hammer pulse
- Quincke's sign (pulsation of the capillary bed in the nail)
- Mayen's sign (diastolic drop of BP>15 mm Hg with arm raised)
- Rosenbach's sign (pulsatile liver)
- Gerhardt's sign (enlarged spleen)
- Duroziez's sign (systolic and diastolic murmurs heard over the
femoral artery when it is gradually compressed)
- Hill's sign (A ≥ 20 mmHg difference in popliteal and brachial
systolic cuff pressures, seen in chronic severe AI)
- Traube's sign (a double sound heard over the femoral artery when
it is compressed distally)
- Lincoln sign (pulsatile popliteal)
- Sherman sign (dorsalis pedis pulse is quickly located &
unexpectedly prominent in age>75 yr)
- Key-Hodgkin murmur of AI is a harsh, raspy murmur caused by
leaflet eventration that occurs in luetic aortopathy
The initial diagnosis may be based on the clinical history,
auscultation of the heart, abnormalities in the pulse, and the results
of a chest x-ray. Other heart problems can cause signs and symptoms
similar to those of aortic valve regurgitation, and it's possible to
have more than one disorder at the same time. Common tests used for
diagnosis of aortic valve regurgitation include:
- Doppler echocardiogram may be used to measure the volume of
blood flowing backward through an aortic valve. This volume is
expressed in cubic centimeters per beat.
- Chest X-ray. X-ray of the chest shows an enlargement of the left
- Electrocardiogram (ECG) may show signs of an enlarged left
- Transesophageal echocardiogram allows more closer look at the
aortic valve and a clear picture of the amount of blood flowing
- Exercise tests: Different types of exercise tests help measure
tolerance for activity and heart's response to exertion (exercise).
- Cardiac catheterization can specifically show the blood leaking
back from the aorta into the left ventricle. Some catheters used in
cardiac catheterization have sensor devices (sensors) at the tips
that can measure pressure within heart chambers, such as the left
ventricle. Pressure may be increased in the left ventricle with
aortic valve regurgitation.
- Coronary angiography is performed before surgery because about
20% of people with aortic regurgitation also have coronary artery
Prevention and Self-careOne possible way to prevent aortic valve
regurgitation is to prevent rheumatic fever. Untreated strep throat can
develop into rheumatic fever. Fortunately, strep throat is easily
treated with antibiotics. Avoiding infections of the blood, including
those caused by intravenous drug use, can prevent damage to the aortic
valve that leads to aortic valve regurgitation. In addition, good
dental care helps prevent bloodstream infections that can damage
your heart valves.
regurgitation can also be prevented from high blood pressure by keeping blood pressure under control. High blood pressure can also cause
the aorta to stretch out, which pulls the aortic valve leaflets apart and
leads to regurgitation.
To maximize the quality of life the following may be recommended in addition to
An individual with aortic regurgitation requires regular visits to the
healthcare provider for monitoring the cardiovascular status and detecting any
signs of deterioration. A woman of childbearing age with aortic valve
regurgitation should discuss pregnancy and family planning with her doctor
because extra burden is put on the heart during pregnancy. Women with symptoms
and/or signs of LV failure should be carefully monitored throughout labor and
delivery with strict attention to volume status and blood pressure. As is true
for mitral valve regurgitation, surgery during pregnancy should be contemplated only for control of
refractory Class III or IV symptoms. Consideration regarding LV size or systolic
function in less symptomatic patients should not apply.
- Control of high blood pressure.
- Consuming less salt.
- Regular dental care.
- Maintaining a healthy weight.
- Regular cardiology check up.
Some cases of aortic insufficiency can be prevented by treating underlying
disorders. For example, effective treatment of autoimmune disorders may prevent
some damage to the aortic valve. High blood pressure can be managed with
lifestyle changes and medicines. Following safer sex guidelines can prevents
Isolated AR, like MR, can usually be managed medically with a combination of
diuretics and, if necessary, vasodilator therapy.
Chronic aortic incompetence
Heart failure due to aortic regurgitation can initially be treated
with drugs. Unless aortic regurgitation is mild, surgery is ultimately
almost always required. In the weeks before surgery, heart failure is
treated with digoxin, diuretics, and a drug that dilates blood vessels
and thus reduces the work of the heart, such as a calcium blocker (e.g.
nifedipine), an angiotensin-converting enzyme (ACE) inhibitor, or hydralazine, plus a
nitrate. An angiotensin II receptor blocker may be used when an ACE
inhibitor cannot be used. Vasodilator therapy may delay the progression
to valve replacement. Use of a pacemaker to increase the heart rate
can sometimes help reduce the severity of heart failure.
2. Valve replacement
In chronic aortic regurgitation, surgery is indicated if the patient
has symptoms. The damaged valve should be surgically replaced with an artificial
valve before the left ventricle becomes irreversibly damaged and heart
failure becomes too severe. Usually, echocardiography is performed periodically to determine how
rapidly the left ventricle is enlarging, so that surgery can be
scheduled at an appropriate time. Ventricular cavity enlargement more
than 55 mm is an indication for surgical intervention. People with aortic regurgitation, even
when mild, are at increased risk for developing an infection of the
valve (endocarditis). They need to take antibiotics before certain
dental or surgical procedures.
Acute aortic incompetence
1. Valve replacement
If regurgitation occurs quickly, the aortic valve is usually
replaced as soon as possible.
2. Valve repair
If the cause of AI is endocarditis or
aortic dissection, the valve may in some cases be repaired instead.
Prognosis and survival
Without treatment, aortic regurgitation tends to worsen over time.
The outlook is worse for older people, partly because many of them also
have coronary artery disease. If heart failure develops, the outlook is
also worse. After heart valve replacement, people over 75 tend to
continue to have heart problems (including heart failure) and are more
likely to die.
If a person does not have symptoms and the left heart chamber works
well, he or she may remain on medicine for a long time. Successful
replacement of the valve restores normal blood flow. The long-term
outcome is usually very good. Artificial valves wear out over a period
of years. Their function is monitored, and the valves are replaced as
necessary. Some artificial valves require that the person take
antibiotics before and after surgeries or dental work to avoid serious
heart infections, and anti-coagulants to avoid blood clots, such as deep