Skip to main content
SpringerLink
Log in

Aortic Regurgitation

  • Structural Heart Disease (RJ Siegel and NC Wunderlich, Section Editors)
  • Published:
Current Cardiology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Aortic regurgitation (AR) is a common form of valvular disease which is characterized by reflux of blood from the aorta into the left ventricle (LV) during diastole. AR results from various etiologies, affecting the aortic valve cusps or the aortic root. The clinical presentation of patients with AR depends on the severity of the regurgitation and differs whether AR develops acutely or if it progresses over a prolonged period, allowing the cardiac chambers to adapt. Echocardiography is the primary method to determine the etiology of AR and to define its severity. We review the current data regarding the diagnosis and treatment of AR.

Recent Findings

No single parameter is sufficient to determine AR severity; thus, an integrative, multi-parametric approach is required. Echocardiography is key for imaging the aortic valve morphology and flow as well as aortic root and ascending aorta. Determining LV ejection fraction and dimensions is essential for patient management and optimizing timing for intervention. Three-dimensional (3D) echocardiography is useful in the evaluation of AR etiology and severity. The use of Trasncatheter aortic valve replacement (TAVR) has emerged as an alternative to surgery in patients at high operative risk.

Summary

The diagnosis and management of AR requires a comprehensive approach and routine clinical and echocardiographic follow-up. Surgical or percutaneous therapy is indicated when symptoms develop and in those who have LV dysfunction or LV dilation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Supino PG, Borer JS, Preibisz J, Bornstein A. The epidemiology of valvular heart disease: a growing public health problem. Heart Fail Clin. 2006;2(4):379–93. https://doi.org/10.1016/j.hfc.2006.09.010.

    Article  PubMed  Google Scholar 

  2. Siu SC, Silversides CK. Bicuspid aortic valve disease. J Am Coll Cardiol. 2010;55(25):2789–800. https://doi.org/10.1016/j.jacc.2009.12.068.

    Article  PubMed  Google Scholar 

  3. Ross J Jr. Afterload mismatch in aortic and mitral valve disease: implications for surgical therapy. J Am Coll Cardiol. 1985;5(4):811–26.

    Article  PubMed  Google Scholar 

  4. Goldbarg SH, Halperin JL. Aortic regurgitation: disease progression and management. Nat Clin Pract Cardiovasc Med. 2008;5(5):269–79. https://doi.org/10.1038/ncpcardio1179.

    Article  PubMed  Google Scholar 

  5. Sutton M, Plappert T, Spiegel A, Raichlen J, Douglas P, Reichek N, et al. Early postoperative changes in left ventricular chamber size, architecture, and function in aortic stenosis and aortic regurgitation and their relation to intraoperative changes in afterload: a prospective two-dimensional echocardiographic study. Circulation. 1987;76(1):77–89.

    Article  CAS  PubMed  Google Scholar 

  6. Carabello BA. Aortic regurgitation. A lesion with similarities to both aortic stenosis and mitral regurgitation. Circulation. 1990;82(3):1051–3.

    Article  CAS  PubMed  Google Scholar 

  7. Wisenbaugh T, Spann JF, Carabello BA. Differences in myocardial performance and load between patients with similar amounts of chronic aortic versus chronic mitral regurgitation. J Am Coll Cardiol. 1984;3(4):916–23.

    Article  CAS  PubMed  Google Scholar 

  8. Grossman W, Jones D, McLaurin LP. Wall stress and patterns of hypertrophy in the human left ventricle. J Clin Invest. 1975;56(1):56–64. https://doi.org/10.1172/JCI108079.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Rigolin VH, Bonow RO. Hemodynamic characteristics and progression to heart failure in regurgitant lesions. Heart Fail Clin. 2006;2(4):453–60. https://doi.org/10.1016/j.hfc.2006.09.009.

    Article  PubMed  Google Scholar 

  10. Nitenberg A, Foult JM, Antony I, Blanchet F, Rahali M. Coronary flow and resistance reserve in patients with chronic aortic regurgitation, angina pectoris and normal coronary arteries. J Am Coll Cardiol. 1988;11(3):478–86.

    Article  CAS  PubMed  Google Scholar 

  11. Tamborini G, Barbier P, Doria E, Bortone F, Sisillo E, Susini G, et al. Coronary flow and left ventricular diastolic function in aortic regurgitation. Coron Artery Dis. 1995;6(8):635–43.

    Article  CAS  PubMed  Google Scholar 

  12. Mann DL, Zipes DP, Libby P, Bonow RO, Braunwald E. Braunwald’s heart disease : a textbook of cardiovascular medicine. Tenth ed. Philadelphia: Elsevier/Saunders; 2015.

  13. Fortuin NJ, Craige E. On the mechanism of the Austin Flint murmur. Circulation. 1972;45(3):558–70.

    Article  CAS  PubMed  Google Scholar 

  14. Bekeredjian R, Grayburn PA. Valvular heart disease: aortic regurgitation. Circulation. 2005;112(1):125–34. https://doi.org/10.1161/CIRCULATIONAHA.104.488825.

    Article  PubMed  Google Scholar 

  15. Thomson HL, Basmadjian AJ, Rainbird AJ, Razavi M, Avierinos JF, Pellikka PA, et al. Contrast echocardiography improves the accuracy and reproducibility of left ventricular remodeling measurements: a prospective, randomly assigned, blinded study. J Am Coll Cardiol. 2001;38(3):867–75.

    Article  CAS  PubMed  Google Scholar 

  16. La Canna G, Maisano F, De Michele L, Grimaldi A, Grassi F, Capritti E, et al. Determinants of the degree of functional aortic regurgitation in patients with anatomically normal aortic valve and ascending thoracic aorta aneurysm. Transoesophageal Doppler echocardiography study. Heart. 2009;95(2):130–6. https://doi.org/10.1136/hrt.2007.134494.

    Article  PubMed  Google Scholar 

  17. Perry GJ, Helmcke F, Nanda NC, Byard C, Soto B. Evaluation of aortic insufficiency by Doppler color flow mapping. J Am Coll Cardiol. 1987;9(4):952–9.

    Article  CAS  PubMed  Google Scholar 

  18. •• Zoghbi WA, Adams D, Bonow RO, Enriquez-Sarano M, Foster E, Grayburn PA, et al. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the American Society of Echocardiography developed in collaboration with the Society for Cardiovascular Magnetic Resonance. J Am Soc Echocardiogr. 2017;30(4):303–71. https://doi.org/10.1016/j.echo.2017.01.007 This report is a state-of-the-art comprehensive review on the echocardiographic assessment of valvular regurgitation.

    Article  PubMed  Google Scholar 

  19. Tribouilloy CM, Enriquez-Sarano M, Bailey KR, Seward JB, Tajik AJ. Assessment of severity of aortic regurgitation using the width of the vena contracta: a clinical color Doppler imaging study. Circulation. 2000;102(5):558–64.

    Article  CAS  PubMed  Google Scholar 

  20. Perez de Isla L, Zamorano J, Fernandez-Golfin C, Ciocarelli S, Corros C, Sanchez T, et al. 3D color-Doppler echocardiography and chronic aortic regurgitation: a novel approach for severity assessment. Int J Cardiol. 2013;166(3):640–5. https://doi.org/10.1016/j.ijcard.2011.11.094.

    Article  PubMed  Google Scholar 

  21. Skaug TR, Amundsen BH, Hergum T, Urheim S, Torp H, Haugen BO. Quantification of aortic regurgitation using high-pulse repetition frequency three-dimensional colour Doppler. Eur Heart J Cardiovasc Imaging. 2014;15(6):615–22. https://doi.org/10.1093/ehjci/jet255.

    Article  PubMed  Google Scholar 

  22. Enriquez-Sarano M, Miller FA Jr, Hayes SN, Bailey KR, Tajik AJ, Seward JB. Effective mitral regurgitant orifice area: clinical use and pitfalls of the proximal isovelocity surface area method. J Am Coll Cardiol. 1995;25(3):703–9. https://doi.org/10.1016/0735-1097(94)00434-R.

    Article  CAS  PubMed  Google Scholar 

  23. Tribouilloy CM, Enriquez-Sarano M, Fett SL, Bailey KR, Seward JB, Tajik AJ. Application of the proximal flow convergence method to calculate the effective regurgitant orifice area in aortic regurgitation. J Am Coll Cardiol. 1998;32(4):1032–9.

    Article  CAS  PubMed  Google Scholar 

  24. Labovitz AJ, Ferrara RP, Kern MJ, Bryg RJ, Mrosek DG, Williams GA. Quantitative evaluation of aortic insufficiency by continuous wave Doppler echocardiography. J Am Coll Cardiol. 1986;8(6):1341–7.

    Article  CAS  PubMed  Google Scholar 

  25. Teague SM, Heinsimer JA, Anderson JL, Sublett K, Olson EG, Voyles WF, et al. Quantification of aortic regurgitation utilizing continuous wave Doppler ultrasound. J Am Coll Cardiol. 1986;8(3):592–9.

    Article  CAS  PubMed  Google Scholar 

  26. Tribouilloy C, Avinee P, Shen WF, Rey JL, Slama M, Lesbre JP. End diastolic flow velocity just beneath the aortic isthmus assessed by pulsed Doppler echocardiography: a new predictor of the aortic regurgitant fraction. Br Heart J. 1991;65(1):37–40.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  27. Reimold SC, Maier SE, Aggarwal K, Fleischmann KE, Piwnica-Worms D, Kikinis R, et al. Aortic flow velocity patterns in chronic aortic regurgitation: implications for Doppler echocardiography. J Am Soc Echocardiogr. 1996;9(5):675–83.

    Article  CAS  PubMed  Google Scholar 

  28. Enriquez-Sarano M, Bailey KR, Seward JB, Tajik AJ, Krohn MJ, Mays JM. Quantitative Doppler assessment of valvular regurgitation. Circulation. 1993;87(3):841–8.

    Article  CAS  PubMed  Google Scholar 

  29. Quinones MA, Otto CM, Stoddard M, Waggoner A, Zoghbi WA. Doppler Quantification Task Force of the N et al. Recommendations for quantification of Doppler echocardiography: a report from the Doppler Quantification Task Force of the Nomenclature and Standards Committee of the American Society of Echocardiography. J Am Soc Echocardiogr. 2002;15(2):167–84.

    Article  PubMed  Google Scholar 

  30. Buser PT, Auffermann W, Holt WW, Wagner S, Kircher B, Wolfe C, et al. Noninvasive evaluation of global left ventricular function with use of cine nuclear magnetic resonance. J Am Coll Cardiol. 1989;13(6):1294–300.

    Article  CAS  PubMed  Google Scholar 

  31. Cranney GB, Lotan CS, Dean L, Baxley W, Bouchard A, Pohost GM. Left ventricular volume measurement using cardiac axis nuclear magnetic resonance imaging. Validation by calibrated ventricular angiography. Circulation. 1990;82(1):154–63.

    Article  CAS  PubMed  Google Scholar 

  32. Cawley PJ, Hamilton-Craig C, Owens DS, Krieger EV, Strugnell WE, Mitsumori L, et al. Prospective comparison of valve regurgitation quantitation by cardiac magnetic resonance imaging and transthoracic echocardiography. Circ Cardiovasc Imaging. 2013;6(1):48–57. https://doi.org/10.1161/CIRCIMAGING.112.975623.

    Article  PubMed  Google Scholar 

  33. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, 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. Circulation. 2014;129(23):e521–643. https://doi.org/10.1161/CIR.0000000000000031.

    Article  PubMed  Google Scholar 

  34. •• Baumgartner H, Falk V, Bax JJ, De Bonis M, Hamm C, Holm PJ, et al. ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2017;38(36):2739–91. https://doi.org/10.1093/eurheartj/ehx391 The European Society of Cardiology (ESC) 2017 guidelines are currently the most recent guidelines for the management of valve diseases.

    Article  PubMed  Google Scholar 

  35. Levine HJ, Gaasch WH. Vasoactive drugs in chronic regurgitant lesions of the mitral and aortic valves. J Am Coll Cardiol. 1996;28(5):1083–91. https://doi.org/10.1016/S0735-1097(96)00288-4.

    Article  CAS  PubMed  Google Scholar 

  36. Shen WF, Roubin GS, Hirasawa K, Uren RF, Hutton BF, Harris PJ, et al. Noninvasive assessment of acute effects of nifedipine on rest and exercise hemodynamics and cardiac function in patients with aortic regurgitation. J Am Coll Cardiol. 1984;4(5):902–7.

    Article  CAS  PubMed  Google Scholar 

  37. Elder DH, Wei L, Szwejkowski BR, Libianto R, Nadir A, Pauriah M, et al. The impact of renin-angiotensin-aldosterone system blockade on heart failure outcomes and mortality in patients identified to have aortic regurgitation: a large population cohort study. J Am Coll Cardiol. 2011;58(20):2084–91. https://doi.org/10.1016/j.jacc.2011.07.043.

    Article  CAS  PubMed  Google Scholar 

  38. Sampat U, Varadarajan P, Turk R, Kamath A, Khandhar S, Pai RG. Effect of beta-blocker therapy on survival in patients with severe aortic regurgitation results from a cohort of 756 patients. J Am Coll Cardiol. 2009;54(5):452–7. https://doi.org/10.1016/j.jacc.2009.02.077.

    Article  PubMed  Google Scholar 

  39. Allen BD, Markl M, Barker AJ, van Ooij P, Carr JC, Malaisrie SC, et al. Influence of beta-blocker therapy on aortic blood flow in patients with bicuspid aortic valve. Int J Card Imaging. 2016;32(4):621–8. https://doi.org/10.1007/s10554-015-0819-3.

    Article  Google Scholar 

  40. Cohn LH, Birjiniuk V. Therapy of acute aortic regurgitation. Cardiol Clin. 1991;9(2):339–52.

    Article  CAS  PubMed  Google Scholar 

  41. Ergin MA, McCullough J, Galla JD, Lansman SL, Griepp RB. Radical replacement of the aortic root in acute type A dissection: indications and outcome. Eur J Cardiothorac Surg. 1996;10(10):840–4 discussion 5.

    Article  CAS  PubMed  Google Scholar 

  42. Pompilio G, Brockmann C, Bruneau M, Buche M, Amrani M, Louagie Y, et al. Long-term survival after aortic valve replacement for native active infective endocarditis. Cardiovasc Surg. 1998;6(2):126–32.

    Article  CAS  PubMed  Google Scholar 

  43. Edwards FH, Peterson ED, Coombs LP, DeLong ER, Jamieson WR, Shroyer ALW, et al. Prediction of operative mortality after valve replacement surgery. J Am Coll Cardiol. 2001;37(3):885–92.

    Article  CAS  PubMed  Google Scholar 

  44. Aronow WS, Ahn C, Kronzon I, Nanna M. Prognosis of patients with heart failure and unoperated severe aortic valvular regurgitation and relation to ejection fraction. Am J Cardiol. 1994;74(3):286–8.

    Article  CAS  PubMed  Google Scholar 

  45. Klodas E, Enriquez-Sarano M, Tajik AJ, Mullany CJ, Bailey KR, Seward JB. Optimizing timing of surgical correction in patients with severe aortic regurgitation: role of symptoms. J Am Coll Cardiol. 1997;30(3):746–52.

    Article  CAS  PubMed  Google Scholar 

  46. Dujardin KS, Enriquez-Sarano M, Schaff HV, Bailey KR, Seward JB, Tajik AJ. Mortality and morbidity of aortic regurgitation in clinical practice. A long-term follow-up study. Circulation. 1999;99(14):1851–7.

    Article  CAS  PubMed  Google Scholar 

  47. Kari FA, Siepe M, Sievers HH, Beyersdorf F. Repair of the regurgitant bicuspid or tricuspid aortic valve: background, principles, and outcomes. Circulation. 2013;128(8):854–63. https://doi.org/10.1161/CIRCULATIONAHA.113.002475.

    Article  PubMed  Google Scholar 

  48. Brown JM, O’Brien SM, Wu C, Sikora JAH, Griffith BP, Gammie JS. Isolated aortic valve replacement in North America comprising 108,687 patients in 10 years: changes in risks, valve types, and outcomes in the Society of Thoracic Surgeons National Database. J Thorac Cardiovasc Surg. 2009;137(1):82–90. https://doi.org/10.1016/j.jtcvs.2008.08.015.

    Article  PubMed  Google Scholar 

  49. Martin E, Dagenais F, Voisine P, Dumont E, Charbonneau E, Baillot R, et al. Surgical aortic valve replacement outcomes in the transcatheter era. J Thorac Cardiovasc Surg. 2015;150(6):1582–8. https://doi.org/10.1016/j.jtcvs.2015.08.077.

    Article  PubMed  Google Scholar 

  50. Iung B, Baron G, Butchart EG, Delahaye F, Gohlke-Bärwolf C, Levang OW, et al. A prospective survey of patients with valvular heart disease in Europe: the Euro Heart Survey on Valvular Heart Disease. Eur Heart J. 2003;24(13):1231–43.

    Article  PubMed  Google Scholar 

  51. Franzone A, Piccolo R, Siontis GC, Lanz J, Stortecky S, Praz F, et al. Transcatheter aortic valve replacement for the treatment of pure native aortic valve regurgitation: A Systematic Review. JACC Cardiovasc Interv. 2016;9(22):2308–17. https://doi.org/10.1016/j.jcin.2016.08.049.

    Article  PubMed  Google Scholar 

  52. • Yoon SH, Schmidt T, Bleiziffer S, Schofer N, Fiorina C, Munoz-Garcia AJ, et al. Transcatheter aortic valve replacement in pure native aortic valve regurgitation. J Am Coll Cardiol. 2017;70(22):2752–63. https://doi.org/10.1016/j.jacc.2017.10.006 This study is currently the largest registry of TAVR in pure aortic regurgitation, providing important outcome data.

    Article  PubMed  Google Scholar 

  53. Urena M, Himbert D, Ohlmann P, Capretti G, Goublaire C, Kindo M, et al. Transcatheter aortic valve replacement to treat pure aortic regurgitation on noncalcified native valves. J Am Coll Cardiol. 2016;68(15):1705–6. https://doi.org/10.1016/j.jacc.2016.07.746.

    Article  PubMed  Google Scholar 

  54. Wernly B, Eder S, Navarese EP, Kretzschmar D, Franz M, Alushi B, et al. Transcatheter aortic valve replacement for pure aortic valve regurgitation: “on-label” versus “off-label” use of TAVR devices. Clin Res Cardiol. 2019. https://doi.org/10.1007/s00392-019-01422-0.

  55. Beigel R, Siegel RJ. Aortic regurgitation: pathophysiology. In: Lang R, Goldstein SA, Kronzon I, Khandheria BK, Mor-Avi V, editors. ASE’s comprehensive echocardiography. second ed. Philadelphia: Elsevier Saunders; 2016. p. 442–6.

Download references

Author information

Authors and Affiliations

  1. Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA

    Nir Flint, Hezzy Shmueli & Robert J. Siegel

  2. Department of Cardiology, Tel-Aviv Sourasky Medical Center affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel

    Nir Flint & Hezzy Shmueli

  3. Cardiovascular Center Darmstadt, Darmstadt, Germany

    Nina C. Wunderlich

  4. The Leviev Heart Center, Sheba Medical Center, Tel-Hashomer, affiliated to the Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel

    Sagit Ben-Zekry & Roy Beigel

Authors
  1. Nir Flint
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nina C. Wunderlich
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hezzy Shmueli
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sagit Ben-Zekry
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Robert J. Siegel
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Roy Beigel
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Roy Beigel.

Ethics declarations

Conflict of Interest

Nir Flint, Nina C. Wunderlich, Hezzy Shmueli, Sagit Ben-Zekry, Robert J. Siegel, and Roy Beigel declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Structural Heart Disease

Electronic Supplementary Material

Transesophageal echo long-axis view with and without color Doppler showing thickened aortic cusps and malcoaptation secondary to a flail right aortic cusp. There is severe aortic regurgitation with an eccentric regurgitant jet directed towards the anterior mitral leaflet. (AVI 6084 kb)

Transesophageal echo long-axis view showing malcoaptation of the aortic valve cusps secondary to severe dilation of the aortic root and ascending aorta. (AVI 14969 kb)

Color Doppler from the same patient as in video 2 showing severe aortic regurgitation (AR). Note the large flow convergence and vena contracta as well as the regurgitant jet which fills most of the left ventricular outflow tract, all consistent with severe AR. (AVI 8915 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Flint, N., Wunderlich, N.C., Shmueli, H. et al. Aortic Regurgitation. Curr Cardiol Rep 21, 65 (2019). https://doi.org/10.1007/s11886-019-1144-6

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11886-019-1144-6

Keywords

Search

Navigation