Aortic Regurgitation (incompetence)

Overview

Definition

Aortic regurgitation (aortic incompetence): Incomplete closure of the aortic valve allows blood to flow backward from the aorta into the left ventricle during diastole.

Diastole: The phase of the cardiac cycle when the ventricles relax and fill with blood; aortic regurgitation occurs during this phase.

Diastolic murmur: An abnormal heart sound heard after the second heart sound (S2), while the ventricles are filling; aortic regurgitation produces a diastolic murmur.

Infective endocarditis: Infection of the inner lining of the heart, usually involving a valve; damage to the aortic valve can cause regurgitation.

Aortic dissection: A tear in the inner layer of the aortic wall that allows blood to separate its layers; involvement near the aortic valve can cause acute aortic regurgitation.

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

Get access to premium images

Diagnosis

Investigations

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

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

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.
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.
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.
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.
Bekeredjian R, Grayburn PA. Valvular heart disease: aortic regurgitation. Circulation. 2005;112(1):125–134. doi:10.1161/CIRCULATIONAHA.104.488825.