Aortic Regurgitation (incompetence)

Overview

• Patients with acute mitral regurgitation (MR) are often gravely ill with significant hemodynamic abnormalities that require urgent medical and usually surgical treatment.
• Aortic Reguritation produces a “diastolic murmur”, which is a murmur heart after the second heart sound (S2 – aortic and pulmonary valve closure) when the ventricles are filled with blood.

Aetiology & Risk Factors

Aetiology

• Endocarditis
• Aortic dissection
• Rupture of congenitally fenestrated cusp
• Traumatic rupture of valve leaflets
• Iatrogenic – complications of aortic balloon valvotomy

Risk Factors

• Bicuspid or rarely unicuspid aortic valve
• Rheumatic fever
• Endocarditis
• Marfan’s Syndrome
• Aortitis

Clinical Manifestations

• Syncope
• Dyspnoea
• Fatigue
• Tachycardia
• Orthopnoea
• Paroxysmal nocturnal dyspnoea
• Signs of pulmonary oedema
• Signs and symptoms of cardiogenic shock in chronicaortic regurgitation
  • Pallor
  • Hypotension
  • Diaphoresis
  • Cyanosis

Cardiovascular Examination

• Signs and cardiogenic shock in chronic regurgitation
• Possible signs of aortic stenosis
• Carotid collapsing pulse (high amplitude pulse of short durations
• Auscultation – Aortic valve (right second intercostal space)
  • Soft or absent S1
  • S2 is soft, while pulmonary valve has increased sound reflecting pulmonary hypertension
  • An S3 is frequently heard but an S4 is absent

Diagnosis

Differential Diagnosis

• Mitral regurgitation
• Mitral stenosis
• Aortic stenosis
• Pulmonary regurgitation

Investigations

• ECG – May show non-specific ST and T wave changes, left axis deviation
• Chest X-ray
• Echocardiogram
• Doppler studies

Diagnosis

Echocardiography is diagnostic in acute AR. Echocardiography confirms the presence of AR and identifies its severity and cause. The cause of aortic regurgitation can be determined by identification of characteristic findings such as those of aortic valve endocarditis  or aortic dissection.

Treatment

Haemodynamically support pre-op

• Inotropes (dopamine and dobutamine)
• Vasodilators (nitroprusside)

Surgical 

• Urgent aortic valve replacement or repair

Complications & Prognosis

Complications

• Complications with operation
• Congestive heart failure
• arrhythmia’s
• infective endocarditis
• sudden death
• MI

Prognosis

• Mortality is low
• It is important to monitor to see of any developing symptoms or LV dysfunction

References

1. Praz F, Borger MA, Lanz J, et al. 2025 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2025;46(44):4635–4736. doi:10.1093/eurheartj/ehaf194.
2. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease. Circulation. 2021;143(5):e72–e227. doi:10.1161/CIR.0000000000000923.
3. Mazzolai L, Teixido-Tura G, Lanzi S, et al. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J. 2024;45(36):3538–3700. doi:10.1093/eurheartj/ehae179.
4. Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for noninvasive evaluation of native valvular regurgitation. J Am Soc Echocardiogr. 2017;30(4):303–371. doi:10.1016/j.echo.2017.01.007.
5. Bekeredjian R, Grayburn PA. Valvular heart disease: aortic regurgitation. Circulation. 2005;112(1):125–134. doi:10.1161/CIRCULATIONAHA.104.488825.