Aortic Regurgitation: A Leaky Valve

In aortic regurgitation, the aortic valve becomes leaky. A leaky aortic valve often leads to significant heart problems.

The aortic valve guards the opening between the left ventricle and the aorta. The aortic valve opens as the left ventricle begins to pump, allowing blood to eject out of the heart and into the aorta. When the ventricle has finished beating, the aortic valve closes to keep blood from washing back into the left ventricle.

When you develop aortic regurgitation, your aortic valve fails to close completely, thus allowing blood to flow backward from the aorta into the left ventricle. This "regurgitation" of blood causes the heart to work much much harder, and the extra stress on the heart can lead to heart failure and other significant problems.

Causes of Aortic Regurgitation

Several medical disorders can produce aortic regurgitation. These include:

• Endocarditis. Endocarditis (infection of the heart valves) can cause the aortic valve to deteriorate, producing regurgitation.
• Bicuspid aortic valve. Aortic regurgitation can be caused by a bicuspid valve, a congenital condition in which the aortic valve consists of only two "cusps" (i.e., flaps) instead of the normal three. Bicuspid aortic valves are especially prone to the formation of calcium deposits, which often produce aortic stenosis. So patients with a bicuspid aortic valve may develop both stenosis and regurgitation.
• Rheumatic heart disease**.** Until the second half of the 20th century, rheumatic heart disease was the leading cause of aortic regurgitation worldwide. With the advent of antibiotics, rheumatic heart disease has become relatively uncommon in the developed world. However, it is still the leading cause of aortic regurgitation in developing countries.
• Congenital aortic regurgitation. Several types of congenital heart disease can produce aortic regurgitation, including Turner syndrome, tetralogy of Fallot, and truncus arteriosus.
• Dilation of the aortic root. The aortic root is the portion of the aorta immediately above the aortic valve. Several conditions can cause the aortic root to dilate or expand. This dilation can distort the aortic valve itself, causing regurgitation. Some of the causes of aortic root dilation include chronic hypertension, aortitis (inflammation of the aorta, which can be caused by diseases such as syphilis), chest injury, aortic dissection (sudden tearing of the wall of the aorta, caused by degenerative vascular disease), and Marfan syndrome.

What Problems Are Caused by Aortic Regurgitation?

In aortic regurgitation, the left ventricle has to work much harder in order to supply the body's tissues with a sufficient amount of blood. Specifically, with each heartbeat, the ventricle must pump out all the blood that the body needs, plus the amount of blood that regurgitates back into the ventricle. This extra volume of blood causes the heart muscle to thicken (or "hypertrophy") and causes the left ventricle to dilate, and the left ventricular ejection fraction to fall.

This extra stress on the left ventricle eventually can lead to heart failure, and to cardiac arrhythmias such as atrial fibrillation, ventricular tachycardia, and ventricular fibrillation.

Mild forms of aortic regurgitation usually produce no symptoms. However, if the regurgitation worsens, the ventricle becomes more stressed and heart failure begins to develop. At this stage, a person with aortic regurgitation will begin to notice dyspnea (shortness of breath) with exertion and early fatigue. These symptoms worsen as the regurgitation becomes more significant, and eventually can become quite severe.

Acute aortic regurgitation is most commonly caused by endocarditis, aortic dissection, or chest trauma. Acute aortic regurgitation often produces sudden and severe heart failure, and can only be treated with emergency valve replacement surgery.

How Is Aortic Regurgitation Diagnosed?

The diagnosis of aortic regurgitation is pretty straightforward. Aortic regurgitation causes a characteristic heart murmur that most healthcare providers will recognize immediately. The diagnosis can be easily confirmed or ruled out with an echocardiogram.

Assessing the severity of aortic regurgitation is important when it comes to making a decision about whether, or when, it is necessary to offer surgical therapy. While the echocardiogram is often very useful in measuring the severity of the valve problem, a cardiac MRI and/or a cardiac catheterization may be necessary to complete the evaluation.

Treatment

Ultimately, treating aortic regurgitation requires surgical replacement of the damaged valve. Drugs that dilate the blood vessels (most often, calcium channel blockers or ACE inhibitors) can help to reduce the amount of blood leaking back into the left ventricle and can help to control symptoms. 

The optimal timing of surgery is very important. As a general rule, aortic valve surgery should be performed just before the aortic regurgitation begins producing symptoms. Periodic physical exams and especially periodic echocardiograms are helpful in optimizing the timing of surgery.

Another important decision is the type of replacement valve that will be used. Prosthetic aortic valves either consist entirely of man-made materials (mechanical valves) or are made from the heart valve of an animal, generally a pig (bioprosthetic valve). Deciding which type of artificial valve to use depends on the patient’s age and whether taking chronic anticoagulation is a problem. 

All artificial heart valves have an increased propensity to form blood clots. However, blood clotting is less of a problem with bioprosthetic than mechanical valves, so people with the bioprosthetic valves may not have to take an anticoagulant, while those with mechanical valves always do. On the other hand, mechanical valves generally last longer than bioprosthetic valves. 

In addition, a minimally invasive type of aortic valve replacement is now FDA approved—transcatheter aortic valve implantation, or TAVI. While the surgery for TAVI is significantly less invasive than for typical valve replacement, this procedure still carries substantial risk. Generally, today it is reserved for patients who are deemed “too sick” for standard valve replacement. However, as experience with TAVI is accumulated, it will undoubtedly become available to broader categories of patients who need an aortic valve replacement.

So: If you need valve replacement for aortic regurgitation, and you are under age 65 or 70 and can take an anticoagulant, your healthcare provider will likely recommend a mechanical valve. If you are older than 65 or 70, or you cannot take an anticoagulant, a bioprosthetic valve will probably be recommended. If your surgical risk is deemed to be very high, a TAVI should be considered.

The bottom line is that there are pros and cons to all types of replacement valves. Deciding the optimal type of valve should be a shared decision between you and your healthcare provider.

A Word From Verywell

Aortic regurgitation—a leaky aortic valve—is potentially a serious problem. If the regurgitation becomes severe enough, aortic valve replacement will be necessary to prevent heart failure and other cardiac problems from developing.