• Clinical science

Aortic regurgitation (Aortic insufficiency)

Summary

Aortic regurgitation (AR) is a valvular heart disease characterized by incomplete closure of the aortic valve that leads to reflux of blood from the aorta into the left ventricle (LV) during diastole. Aortic regurgitation may be acute (occurring primarily after bacterial endocarditis or aortic dissection) or chronic (due to congenital bicuspid valve or rheumatic fever) and may be caused by valvular disease or an abnormality of the aorta. In most cases, acute AR leads to rapid deterioration of LV function with subsequent pulmonary edema and cardiac decompensation. Frequently, chronic AR may remain compensated for a long period of time, becoming symptomatic only when left heart failure develops. Auscultation reveals an S3 and a high-pitched, decrescendo early diastolic murmur. Another characteristic diagnostic finding is widened pulse pressure. Echocardiography is the most important diagnostic tool, both for confirming the diagnosis and determining the severity of disease. In asymptomatic patients, conservative treatment consists of symptom management and physical activity as tolerated. However, symptomatic patients or those with severely reduced LV function should undergo surgical aortic valve replacement.

Etiology

References:[1][2][3][4]

Pathophysiology

References:[1][2][3]

Clinical features

References:[1][2]

Diagnostics

Physical examination

Confirmatory tests

  • Transthoracic echocardiogram (TTE)
    • Indicated for suspected AR as well as to monitor confirmed AR to determine the staging and optimal timing of surgery
    • Findings
      • Abnormal aortic valve leaflets
      • Regurgitant AR jet on Doppler flow tracing
      • Increased LV size and volume
      • Dilated aorta
      • Fluttering of anterior mitral valve leaflet
  • Transesophageal echocardiogram (TEE): indicated if suboptimal or nondiagnostic TTE

Screening tests (optional)

References:[5][6][1][2][3]

Treatment

Conservative

  • Indication: asymptomatic patients and symptomatic patients who are not candidates for surgical treatment
  • Treatment of heart failure
  • Physical activity , but without excessive straining

Surgical

References:[1][3]

Prognosis

  • Asymptomatic patients with normal EF: progression to symptoms or LV dysfunction at a rate of < 6% per year
  • Asymptomatic patients with decreased EF: progression to symptoms at a rate of > 25% per year
  • Symptomatic patients: mortality rate is > 10% per year

References:[1]

  • 1. Wang SS. Aortic Regurgitation. In: Aortic Regurgitation. New York, NY: WebMD. http://emedicine.medscape.com/article/150490-overview. Updated February 24, 2017. Accessed February 26, 2017.
  • 2. Gaasch WH. Clinical Manifestations and Diagnosis of Chronic Aortic Regurgitation in Adults. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-chronic-aortic-regurgitation-in-adults. Last updated April 10, 2015. Accessed April 9, 2017.
  • 3. Maurer G. Aortic regurgitation. Heart. 2006; 92(7): pp. 994–1000. doi: 10.1136/hrt.2004.042614.
  • 4. Cheitlin MD. Surgery for chronic aortic regurgitation: When should it be considered?. Am Fam Physician. 2001; 64(10): pp. 1709–1716. url: https://www.aafp.org/afp/2001/1115/p1709.html.
  • 5. Agabegi SS, Agabegi ED. Step-Up To Medicine. Baltimore, MD, USA: Wolters Kluwer Health; 2015.
  • 6. Walker HK, Hall WD, Hurst WJ, Silverman ME, Morrison G. Clinical Methods: The History, Physical, and Laboratory Examinations. Boston, MA: Butterworths; 1990.
  • 7. Nishimura RA et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary. J Am Coll Cardiol. 2014; 63(22): pp. 2438–2488. doi: 10.1016/j.jacc.2014.02.537.
  • Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014; 63(22): pp. e57–185. doi: 10.1016/j.jacc.2014.02.536.
  • Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. Harrison's Principles of Internal Medicine, Twentieth Edition (Vol.1 & Vol.2). McGraw-Hill Education / Medical; 2018.
  • Karen K. Stout, Edward D. Verrier. Acute Valvular Regurgitation. Circulation. 2009; 119(25): pp. 3232–3241. doi: 10.1161/circulationaha.108.782292.
  • Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of Rheumatic Fever and Diagnosis and Treatment of Acute Streptococcal Pharyngitis. Circulation. 2009; 119(11): pp. 1541–1551. doi: 10.1161/circulationaha.109.191959.
  • Arias EA, Bhan A, Lim ZY, et al. TAVI for Pure Native Aortic Regurgitation: Are We There Yet?. Interventional Cardiology Review. 2019; 14(1): p. 26. doi: 10.15420/icr.2018.37.1.
  • Yoon S-H, Schmidt T, Bleiziffer S, et al. Transcatheter Aortic Valve Replacement in Pure Native Aortic Valve Regurgitation. Journal of the American College of Cardiology. 2017; 70(22): pp. 2752–2763. doi: 10.1016/j.jacc.2017.10.006.
  • Franzone A, Pilgrim T, Stortecky S, Windecker S. Evolving Indications for Transcatheter Aortic Valve Interventions. Current Cardiology Reports. 2017; 19(11). doi: 10.1007/s11886-017-0921-3.
last updated 09/03/2020
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