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Definition
Aortic valve regurgitation, also known as aortic insufficiency or aortic incompetence, is a condition that occurs when your heart's aortic valve doesn't close tightly. In this condition, some of the blood that was just pumped out of your heart leaks back into it.
The leakage of blood may prevent your heart from efficiently pumping blood out to the rest of your body. If your heart isn't working efficiently, you may feel fatigued and short of breath.
Aortic valve regurgitation, which has several causes, can develop suddenly or over decades. Once the condition becomes severe, surgery is usually required to repair or replace the aortic valve.
Symptoms
Most often aortic valve regurgitation develops gradually, and your heart compensates for the problem. You may have no signs or symptoms for many years, and you may even be unaware that you have this condition.
However, as aortic valve regurgitation progresses, signs and symptoms usually appear and may include:
- Fatigue and weakness, especially when you increase your activity level
- Shortness of breath, especially with exertion or when you lie flat
- Chest pain, discomfort or tightness, often increasing during exercise
- Fainting
- Rapid or irregular pulse
- Heart palpitations — sensations of a rapid, fluttering heartbeat
- Swollen ankles and feet
Causes
Aortic valve regurgitation disrupts the way blood normally flows through your heart and its valves.
Your heart, the center of your circulatory system, consists of four chambers. The two upper chambers, the atria, receive blood. The two lower chambers, the ventricles, pump blood to your lungs and to the rest of your body. Blood flows through your heart's chambers, aided by four heart valves. These valves open and close to let blood flow only in one direction through your heart:
- Tricuspid valve
- Pulmonary valve
- Mitral valve
- Aortic valve
The aortic valve consists of three tightly fitting, triangular-shaped flaps of tissues called leaflets. These leaflets connect to the aorta through a ring of tissue called the annulus.
Heart valves open like a one-way gate. The leaflets of the aortic valve are forced open as the left ventricle contracts and blood flows into the aorta. When all of the blood has gone through the valve and the left ventricle has relaxed, the leaflets swing closed to prevent the blood that has just passed into the aorta from flowing back into the left ventricle.
A defective heart valve is one that fails to either open or close fully. When a valve doesn't close tightly, blood can leak backward. This backward flow through a valve is called regurgitation.
Contributing causes
Any condition that damages a valve can cause regurgitation. Causes of aortic valve regurgitation include:
- A congenital heart defect. You may have been born with an aortic valve that has only one or two leaflets (unicuspid or bicuspid valve) rather than the normal three leaflets. This puts you at risk of developing aortic valve regurgitation at some time in your life.
- Deterioration of the valve with age. The aortic valve opens and shuts tens of thousands of times a day, every day of your life. Aortic valve regurgitation may result from age-related wear and tear on the valve.
- Endocarditis. The aortic valve may be damaged by endocarditis — an infection inside your heart that involves heart valves.
- Rheumatic fever. Rheumatic fever — a complication of strep throat and once a common childhood illness in the United States — can damage the aortic valve, leading to aortic valve regurgitation later in life. Rheumatic fever may damage more than one heart valve, and in more than one way. A damaged heart valve may not open fully or close completely — or both. Rheumatic fever is still prevalent in underdeveloped countries, and some older adults in the United States developed rheumatic fever as children.
- Other causes. Other, rarer conditions that can damage the aortic valve and lead to regurgitation include Marfan syndrome (a disease of connective tissue), ankylosing spondylitis (a spine disorder) and syphilis (a sexually transmitted disease). Damage to the aorta near the site of the aortic valve, such as damage from trauma to your chest or from a tear in the aorta, also can cause backward flow of blood through the valve.
Aortic valve regurgitation — of any cause — can weaken your heart. In aortic valve regurgitation, some blood leaks back into the left ventricle instead of flowing onward to the rest of your body after being pumped into the aorta. This forces the left ventricle to hold more blood. In response, this chamber of your heart may enlarge and thicken. At first these adaptations help the left ventricle pump blood with more force. But eventually these changes weaken the left ventricle — and your heart overall.
Risk factors
Aortic valve regurgitation is most common in men between the ages of 30 and 60. However, women and those older or younger can be affected too.
Your risk is greater if your aortic valve has already been damaged by some other condition, such as endocarditis or rheumatic fever. You also have an increased risk if you were born with a unicuspid or bicuspid aortic valve. Doctors can detect this condition by listening to heart sounds with a stethoscope and with the aid of medical tests. In addition, anyone with Marfan syndrome, ankylosing spondylitis or syphilis is at risk of developing a leaky aortic valve.
When to seek medical advice
Take the signs and symptoms of aortic valve regurgitation seriously and see a doctor if they develop. Sometimes the first indications of aortic valve regurgitation are those of its major complication, heart failure. Signs and symptoms of heart failure — a serious condition — include fatigue, shortness of breath, and swollen ankles and feet.
Tests and diagnosis
Identifying aortic valve regurgitation early is important because the condition can worsen with time, and you may need surgery to correct it.
Your doctor may first suspect that you have aortic valve regurgitation during a routine office visit after listening to your heart with a stethoscope and hearing an abnormal heart sound (heart murmur). Blood leaking through the aortic valve makes a distinct sound.
To begin the evaluation of your heart, your doctor will ask you questions about your health, including signs and symptoms, prior tests and history of heart disease in your family. Next your doctor will perform a physical examination that concentrates on your heart.
From this information, your doctor decides what tests you may need in order to make a diagnosis and develop a treatment plan. For testing, you may be referred to a cardiologist — a doctor who specializes in the study of the heart and its function.
Diagnostic tests
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. Common tests doctors use to diagnose aortic valve regurgitation include:
- Echocardiogram. This test uses sound waves to produce an image of your heart. In an echocardiogram, sound waves are directed at your heart from a wand-like device (transducer) held on your chest. The sound waves bounce off your heart and are reflected back through your chest wall and processed electronically to provide video images of your heart. An echocardiogram helps your doctor get a close look at your aortic valve. A specific type of echocardiogram, a Doppler echocardiogram, may be used. It allows measurements of the volume of blood flowing backward through an aortic valve. This volume is expressed in cubic centimeters per beat.
- Chest X-ray. With an X-ray of your chest, your doctor can study the size and shape of your heart to determine whether your left ventricle is enlarged — a possible sign of damage to the aortic valve.
- Electrocardiogram (ECG). In this test, patches with wires (electrodes) are attached to your skin to measure the electrical impulses given off by your heart. Impulses are recorded as waves displayed on a monitor or printed on paper. An ECG can provide clues about whether the left ventricle is enlarged, a problem which can occur with aortic valve regurgitation.
- Transesophageal echocardiogram. This type of echocardiogram allows an even closer look at your aortic valve. The esophagus, the tube that runs from your throat to your stomach, lies close to your heart. In a traditional echocardiogram, a transducer is moved across your chest to produce the sound waves necessary to create the image of your beating heart. In a transesophageal echocardiogram, a small transducer attached to the end of a tube is inserted down the esophagus. Because the esophagus lies close to your heart, having the transducer there provides a clearer picture of your aortic valve and blood flow through it.
- Exercise tests. Different types of exercise tests help measure your tolerance for activity and check your heart's response to exertion (exercise).
- Cardiac catheterization. In this procedure, a doctor threads a thin tube (catheter) through a blood vessel in your arm or groin, into your heart. The catheter is used to deliver dye into your heart chambers and the blood vessels of your heart. The dye, appearing on X-ray images as it moves through your heart, gives your doctors detailed information about your heart and heart valves. Specifically, it can show if blood is leaking back from the aorta into the heart's left ventricle. Some catheters used in cardiac catheterization have miniature 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.
These tests help your doctors diagnose aortic valve regurgitation, determine how serious the problem is, and decide if your aortic valve needs repair or replacement.
Complications
Aortic valve regurgitation — or any heart valve problem — puts you at risk of endocarditis. Endocarditis is an infection of the heart's inner lining — the endocardium. This membrane lines the four chambers and four valves of your heart. Typically, this infection involves one of the heart valves, especially if it's already damaged. If the aortic valve is leaky, it's more prone to infection than is a healthy valve.
You can develop endocarditis when bacteria from another part of your body spread through your bloodstream and collect in your heart. Doctors used to recommend that some people with aortic valve regurgitation take antibiotics before certain dental or medical procedures to prevent endocarditis, but not anymore. In 2007, the American Heart Association issued new guidelines saying, in part, antibiotics are no longer necessary in most cases for someone with this condition. Your doctor should tell you if antibiotics are necessary for you before such procedures.
When it's mild, aortic valve regurgitation may never pose a serious threat to your health. But when it's severe, aortic valve regurgitation may lead to congestive heart failure. Congestive heart failure is a serious condition in which your heart is unable to pump sufficient blood to meet your body's needs.
Treatments and drugs
Treatment of aortic valve regurgitation depends on the degree of the regurgitation, your signs and symptoms, and whether the regurgitation is affecting your heart function. If you have aortic valve regurgitation, your doctor may evaluate your heart with regular echocardiograms to determine whether damage to your heart is accelerating.
Observation
Some people, especially those with mild regurgitation, need no specific treatment. However, even if you don't have signs and symptoms of aortic valve regurgitation, schedule regular evaluations with your doctor. Observation isn't the same as ignoring the condition. Actively observing the stability or the progression of the condition is important so that you can receive the right treatment at the right time.
Surgery
Once signs and symptoms of aortic valve regurgitation develop, you'll usually need surgery. However, if aortic valve regurgitation is weakening your heart, you may need surgery even if you feel well. While the heart is generally adept at counteracting deficiencies caused by a leaky aortic valve, the problem is that if the valve isn't fixed or replaced in time, the strength of your heart may decline so much that it's permanently weakened. You can avoid that by having surgery at the appropriate time.
The overall function of your heart and the amount of regurgitation help to determine when surgery is necessary. Surgical procedures include:
- Valve repair. Aortic valve repair is surgery to preserve the valve and to improve its function. Occasionally, surgeons can modify the original valve (valvuloplasty) to eliminate backward blood flow. You don't need long-term blood-thinning (anticoagulation) therapy after a valvuloplasty.
- Valve replacement. In many cases, the aortic valve has to be replaced to correct aortic valve regurgitation. In valve replacement surgery, the leaky aortic valve is replaced by an artificial (prosthetic) valve. The two types of artificial valves are mechanical and tissue. Mechanical valves are made from metal and are durable, but they carry the risk of blood clots forming on or near the valve. If you have a mechanical valve, you need to use blood-thinning (anticoagulant) medication for life to prevent blood clots from forming on the valve. Tissue valves generally come from a pig, cow or human-cadaver donor heart. These kinds of valves wear out over time, and you may need another operation to replace the valve. However, an advantage of the tissue valve is that you don't have to use long-term anticoagulation medication. Another type of tissue valve replacement, called an autograft, is sometimes possible. An autograft valve replacement uses your own pulmonary valve — another heart valve — to replace your damaged aortic valve.
Aortic valve surgery usually involves open-heart surgery performed with general anesthesia. Your heart is exposed and connected to a heart-lung machine that assumes your breathing and blood circulation during the procedure. Your surgeon then repairs or replaces your leaky aortic valve.
Aortic valve regurgitation can be eliminated with surgery, and you can usually resume normal activities within a few months. The prognosis following surgery is generally good.
Medications
No medication can eliminate aortic valve regurgitation. However, your doctor may prescribe certain medications to alleviate your symptoms and prevent complications of your condition.
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Vasodilators. These medications (hydralazine, nifedipine), which open your blood vessels, may be prescribed for you if surgery isn't a recommended option. Vasodilators can increase the amount of blood that rushes forward when your heart pumps and decrease the amount of blood that flows backward.
Vasodilators aren't often recommended for people without symptoms, as they usually do fine without treatment.
- Antibiotics. Antibiotics used to be prescribed to people with aortic valve regurgitation to prevent endocarditis, a serious infection in your heart. This is usually no longer the case.
Prevention
One possible way to prevent aortic valve regurgitation is to prevent rheumatic fever. You can do this by making sure you see your doctor when you have a sore throat. 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, taking good care of your teeth helps prevent bloodstream infections that can damage your heart valves.
You may be able to prevent aortic valve regurgitation from high blood pressure by taking care of your cardiovascular system. Getting your blood pressure under control is important because high blood pressure can lead to aortic valve damage and aortic valve regurgitation. High blood pressure can also cause your aorta to stretch out, which pulls the aortic valve leaflets apart and leads to regurgitation.
Lifestyle and home remedies
To maximize your quality of life if you have aortic valve regurgitation, your physician may — in addition to other treatments — recommend that you:
- Control high blood pressure. Lowering blood pressure reduces the strain on your aortic valve.
- Consume less salt. Cutting back on salt in your diet helps you maintain your blood pressure within a normal range, which is important if you have aortic valve regurgitation.
- Maintain a healthy weight. Keep your weight within a range recommended by your doctor. Extra weight makes extra work for your heart.
- Exercise. Follow an exercise program within guidelines recommended by your doctor. Exercise itself does not fix aortic valve regurgitation, but it can help to lower your blood pressure. Exercise also helps maintain your general fitness, which will help with your recovery if you need heart surgery.
- See your doctor regularly. Establish a regular evaluation schedule with your cardiologist or primary care provider.
If you're a woman of childbearing age with aortic valve regurgitation, discuss pregnancy and family planning with your doctor. During pregnancy, your heart works harder. How a heart with aortic valve regurgitation tolerates this extra work depends on the degree of leakage and how well your heart pumps. Should you become pregnant, you'll need evaluation by your cardiologist and obstetrician throughout your pregnancy, labor and delivery, and after delivery.
Last Updated: 09/24/2007
