Aortic Valve Regurgitation

Exams and Tests

You should have a physical exam periodically, with the frequency depending on your age, overall health, and risk factors for various conditions. Most heart valve problems are discovered by a doctor while listening to the heart with a stethoscope. If your doctor finds aortic valve regurgitation during a routine physical, the condition will likely not have progressed to the point of being severe and needing immediate treatment. By treating the condition early, you may be able to extend, possibly even by several years, the time before you need valve replacement surgery. Because all artificial valves eventually wear out, this could mean one fewer valve replacement in your lifetime.

In testing for aortic valve regurgitation, your doctor will try to determine whether you have the condition and what type of regurgitation you have (acute or chronic). The doctor also will want to assess how severe the regurgitation is and whether you have any complications, such as abnormal heartbeats (arrhythmias) or heart failure.

A medical history and physical exam are a routine part of any evaluation of how well your heart is working. Aortic valve regurgitation can generally be diagnosed by physical exam.

Further testing may be needed to find out how much the valve is leaking. Tests also are needed if you have symptoms, because they can easily be confused with symptoms of several other heart conditions, including coronary artery disease (CAD) and heart failure. Aortic valve regurgitation also can be confused with other heart valve conditions.

During the physical exam, your doctor will listen for an extra heart sound (a murmur). If you have a certain type of heart murmur, your doctor may suspect aortic valve regurgitation and suggest further tests, which may include:

• Echocardiogram (echo)/transesophageal echocardiogram (TEE). Echocardiography (echo) can be used to look at the heart valves and the shape of the leaflets and to see whether the valves are leaking. Echocardiograms also measure the ability of the lower left heart chamber (left ventricle) to fill with blood and pump properly. Echo also helps measure heart size and may show whether the heart muscle is abnormally thickened because of aortic valve regurgitation. Doctors use an echo to guide treatment decisions, such as whether to perform valve surgery, which may be needed if there is evidence of an enlarged left ventricle (a sign of heart failure).
• Electrocardiogram (ECG, EKG). The results of electrocardiography (electrocardiogram) may show abnormal electrical activity, suggesting that your heart is enlarged or has an increased workload caused by the backflow of blood or by an arrhythmia.
• Chest X-ray. If you have aortic valve regurgitation, a chest X-ray may show that the lower left ventricle is enlarged. In some cases, the blood vessel leaving the heart (aorta) may be enlarged just beyond the aortic valve.
• Exercise electrocardiogram. Exercise electrocardiography may be needed to see how the heart responds to exercise in a person who does not exercise regularly or when symptoms are present.
• Angiogram/aortogram. During an angiogram of the aorta (aortogram), a thin, flexible tube called a catheter is placed into the femoral artery in the upper thigh and threaded to the left ventricle and aorta. Dye is then injected through the catheter, and the flow of the dye through the aortic valve can help your doctor determine how much the aortic valve is leaking. Also, coronary angiogram, in which the coronary arteries are viewed, is usually done at the same time.
• Radionuclide ventriculogram (nuclear scanning). Ventriculography can measure how well the left ventricle is pumping and how much blood is pumped out of the chamber with each heartbeat.

If you have aortic valve regurgitation, you will see your doctor for regular exams including an echocardiogram. How often you have an echocardiogram depends on the severity of your regurgitation. Mild regurgitation requires an echocardiogram every 2 to 3 years. A moderate condition requires an echo every year. And with severe regurgitation, you may have to have an echo every 4 to 6 months.

Treatment Overview

Treatment for aortic valve regurgitation usually depends on whether you have symptoms from your leaky heart valve and whether your heart is pumping effectively. Other factors that play a part in treatment decisions include your age (older people may be at greater-than-average risk for complications of some treatments), risks associated with surgery, and the experience of the doctor and health care facility performing the procedures.

If you have symptoms, surgical treatment may be needed. If your symptoms develop suddenly (acute aortic regurgitation), immediate surgery to replace the valve is usually needed.

The treatment for acute aortic regurgitation is usually limited to immediate surgery, so this treatment overview will discuss the treatment of chronic aortic valve regurgitation.

Initial treatment

Your doctor will assess the cause and severity of your aortic valve regurgitation and how effectively your heart is able to compensate for it. In addition to some preliminary tests—including routine blood tests and an electrocardiogram—an exercise electrocardiogram (also called exercise EKG or cardiac stress test) can be done. This test will help you and your doctor see whether you have any symptoms while you are exercising.

An echocardiogram will probably be done too. The echocardiogram measures how much your valve is leaking, the size of your left ventricle, and your ejection fraction. These measurements help your doctor know when surgery is needed.

If your regurgitation is mild and you do not have any symptoms, your doctor may not prescribe daily heart medicines. If you have had rheumatic fever, you may need to take antibiotics daily for the following 5 to 10 years, depending on your heart's condition.

If your regurgitation is moderate to severe, your doctor may prescribe a high blood pressure medicine. These medicines include the calcium channel blocker nifedipine, an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB), or the vasodilator hydralazine.

Since your heart is already working overtime to keep up with your body's needs, your doctor will probably recommend specific lifestyle changes to decrease your heart's workload.

• If you smoke, try to quit. Medicines and counseling can help you quit for good.
• Your doctor will also recommend that you follow a heart-healthy diet.
• If you do not have symptoms of aortic valve regurgitation, and your left ventricle is working well, your doctor may recommend regular, light aerobic exercise, such as walking. But do not start an exercise program on your own without first discussing it with your doctor. Your doctor may recommend you have tests to see what sort of exercise is safe for you.
• Good dental hygiene and regular dental checkups are important. Poor dental health can increase the risk of bacteria spreading to your heart.
• Avoid getting sick from the flu. Get a flu shot every year.

Report any symptoms of chest pain, fainting, and shortness of breath to your doctor immediately. You will also need to follow up after 2 or 3 months for another screening and have regular appointments to find out whether your condition is getting worse.

Ongoing treatment

Symptoms of chronic aortic valve regurgitation most commonly develop when you are in your 40s or 50s, but there is no way to gauge how quickly symptoms will develop in each case. Some people remain free of symptoms for decades, while in others, progression to symptoms takes 2 to 3 years.

Regardless, you will need to have regular echocardiograms (echos) to find out whether your aortic regurgitation is getting worse. The echocardiogram estimates your ejection fraction—the amount of blood that is leaving your left ventricle, the heart's main pump—and the size of your left ventricle. A declining ejection fraction and an increasing diameter of your left ventricle indicate decreasing heart function and worsening regurgitation.

Mild regurgitation requires an evaluation with an echocardiogram every 2 to 3 years. A moderate condition requires an echo every year. And with severe regurgitation, you may have to have an echo every 4 to 6 months.

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend having aortic valve replacement surgery if you have severe regurgitation and one of the following conditions:¹

• You have symptoms.
• Your ejection fraction drops below 50% at rest.
• Your left ventricle enlarges to more than 55 millimeters at rest.
• You are going to have another open-heart surgery such as coronary artery bypass graft surgery.

Your doctor may recommend that you have surgery even if you do not have symptoms, because symptoms typically only occur after the condition has progressed to the point that it has already damaged the heart.

It is extremely important that you report any symptoms or changes in your symptoms to your doctor. Your doctor will rely on you to provide an accurate assessment of how you feel and how your symptoms have changed since your last visit.

If you are not already taking medicines, at some point your doctor may prescribe a high blood pressure medicine. These medicines include the calcium channel blocker nifedipine, an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB), or the vasodilator hydralazine.

If aortic valve regurgitation causes chest pain, medicines called nitrates (nitroglycerin) can sometimes be tried to help relieve the pain. Antiarrhythmic medicines may be needed if aortic valve regurgitation leads to abnormal heart rhythms (arrhythmias). If aortic valve regurgitation causes heart failure, medicines such as digoxin and diuretics are often used to help the heart pump more effectively.

People who have had rheumatic fever may need to take antibiotics daily for 5 to 10 years after the infection, depending on the damage to the heart.

Avoid getting sick from the flu. Get a flu shot every year.

Your doctor will stress that you quit smoking and avoid secondhand smoke, eat a heart-healthy diet, limit your sodium intake, and possibly follow an exercise program. If you can exercise, do activities that raise your heart rate. Prescribed exercise is often part of a cardiac rehabilitation program.

Treatment if the condition gets worse

If your aortic valve regurgitation is getting worse and your heart is not able to compensate for the extra workload, your doctor will recommend that you have aortic valve replacement surgery, even if you do not have symptoms. But if you have symptoms, aortic valve replacement surgery is the only cure for aortic regurgitation.

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend having aortic valve replacement surgery if you have severe regurgitation and one of the following conditions:¹

• You have symptoms.
• Your ejection fraction drops below 50% at rest.
• Your left ventricle enlarges to more than 55 millimeters at rest.
• You are going to have another open-heart surgery such as coronary artery bypass graft surgery.

Your doctor may recommend that you have surgery even if you do not have symptoms, because symptoms typically only occur after the condition has progressed to the point that it has already damaged the heart.

Other risk factors, including age, speed of deterioration, and overall health, will also be considered in deciding the timing of surgery.

A small number of people may suffer from other severe and debilitating conditions that make valve replacement surgery too dangerous. Also, some people may choose not to have valve replacement surgery for personal or philosophical reasons. For example, a person may believe that he or she does not have enough remaining years to make surgery worthwhile.

People with symptomatic aortic valve regurgitation who do not have corrective surgery face progression to the severe stages of heart failure and, on average, have a life expectancy of 2 to 4 years. This means they will probably have to cope with an end stage to the disease. As you near the end stage of your condition, you may want to consider making advance directives, which are documents that allow you to determine the type of care you wish to receive in case you are not able to make your wishes known at the end of your life. For more information, see the topic Care at the End of Life.

Ongoing Concerns

After you are diagnosed with long-lasting (chronic) aortic valve regurgitation, be sure to work with your doctor to monitor the condition of your valve and report immediately any shortness of breath, fainting, chest pain, or other symptoms. (Symptoms of acute aortic valve regurgitation come on suddenly. Acute regurgitation is an emergency that requires immediate valve replacement surgery.)

If you do not have symptoms

Many people are surprised when diagnosed with chronic aortic valve regurgitation, because they do not have symptoms. People who have chronic regurgitation, even when it's moderate or severe, can have a good prognosis for many years.

Even though you may feel fine, it is important to guard against a false sense of security during this stage of chronic aortic valve regurgitation. Significant damage can occur to your heart during this period.

If you have symptoms

If you have symptoms, valve replacement surgery is the only cure for aortic valve regurgitation. If you cannot or choose not to have surgery, you likely will develop heart failure and your life span will be greatly reduced. The condition usually reduces average life expectancy to about 2 years if you develop heart failure and 4 years if you develop chest pain (angina).² With corrective surgery, you may reach a normal life expectancy. For more information, see the topic Heart Failure.

Symptoms of chronic regurgitation most commonly develop in a person's 40s or 50s. But there is no way to gauge how quickly symptoms will develop in any one person. Some people can remain symptom-free for decades. In others, progression to symptoms takes 2 to 3 years. You may develop symptoms more quickly if the left ventricle does not contract fully (depressed systolic function).

Complications may develop from severe, symptomatic chronic aortic valve regurgitation. Heart failure, an infection in your heart (endocarditis), and irregular heartbeats (arrhythmias) are all common complications of aortic valve regurgitation that can be delayed if not prevented entirely. Reducing your risk factors for these conditions can help prevent complications. For instance, because both high blood pressure (hypertension) and regurgitation can cause heart failure, if you have both it is especially important to control your blood pressure.

It may be better to have valve replacement surgery before symptoms develop from regurgitation. If the left ventricle becomes significantly enlarged, heart damage can be irreversible. The left ventricle can enlarge even while you are symptom-free. For this reason, visit your doctor regularly for appropriate monitoring.

Living With Aortic Regurgitation

Having aortic valve regurgitation means your heart is working overtime to keep up with your body's needs. So your doctor will probably recommend specific lifestyle changes to decrease your heart's workload.

• If you smoke, try to quit. Medicines and counseling can help you quit for good.
• Your doctor will also recommend that you follow a heart-healthy diet and limit your sodium intake.
• If you do not have symptoms of aortic valve regurgitation and your left ventricle is working well, your doctor may recommend regular, light aerobic exercise, such as walking. But do not start an exercise program on your own without first talking with your doctor. Your doctor may recommend you have tests to see what sort of exercise is safe for you.
• If you are overweight, you may want to try to lose weight to reduce your heart's workload. For more information on losing weight, see the topic Weight Management. The American Heart Association (AHA) publishes dietary guidelines for general heart health.
• Practice good dental hygiene and have regular checkups. Good dental health is especially important, because bacteria can spread from infected teeth and gums to the heart valves.
• Avoid getting sick from the flu. Get a flu shot every year.

If you have an artificial valve, you may need to take antibiotics before you have certain dental or surgical procedures. The antibiotics help prevent an infection in your heart called endocarditis.

People who have had rheumatic fever may need to take antibiotics for 5 to 10 years following the infection, depending on the damage to the heart.

If you have severe aortic valve regurgitation, your doctor will probably recommend that you avoid strenuous physical activity.

If you have chronic aortic regurgitation, you are likely to live for many years without symptoms. During this symptom-free period, you need to monitor the function of the lower left chamber of the heart (left ventricle) with regular doctor visits and echocardiogram tests. How often you need to see your doctor depends on the severity of your condition. Follow-up visits are generally scheduled every 6 to 12 months.

Report any symptoms of chest pain, fainting, and shortness of breath to your doctor immediately. These are signs that you are likely to need surgery.

Medications

Treatment for chronic aortic valve regurgitation includes medicines to reduce blood pressure. If you have valve replacement surgery, you will need to take medicines to prevent infection and blood clots around the artificial valve.

If your regurgitation is moderate to severe, your doctor may prescribe a high blood pressure medicine. These medicines include the calcium channel blocker nifedipine, an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB), or the vasodilator hydralazine.

If aortic valve regurgitation causes chest pain, medicines called nitrates (nitroglycerin) can sometimes be tried to help relieve the pain. Antiarrhythmic medicines may be needed if the regurgitation leads to irregular heart rhythms (arrhythmias). If aortic valve regurgitation causes heart failure, medicines are often used to help the heart pump more effectively. These include digoxin and diuretics.

If your valve is replaced with an artificial heart valve made of plastic, metal, or cloth, you will have to take anticoagulant medicine, such as warfarin (Coumadin), for the rest of your life to prevent blood clots.

When you take warfarin, you need to take extra steps to avoid bleeding problems. You need to:

• Get regular blood tests.
• Prevent falls and injuries.
• Eat a steady diet, and pay attention to foods that contain vitamin K.
• Tell your doctors about all other medicines and vitamins that you take.

For more information, see:

Warfarin: Taking your medicine safely.

If you have an artificial valve, you may need to take antibiotics before you have certain dental or surgical procedures. The antibiotics help prevent an infection in your heart called endocarditis.

People who have had rheumatic fever may need to take antibiotics for 5 to 10 years after the infection, depending on the damage to the heart.

Surgery

Valve replacement surgery is the only cure for sudden (acute) aortic valve regurgitation or for long-term (chronic) regurgitation when symptoms develop or signs show that the lower left heart chamber (left ventricle) is starting to fail.

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend having aortic valve replacement surgery if you have severe regurgitation and one of the following conditions:¹

• You have symptoms.
• Your ejection fraction drops below 50% at rest.
• Your left ventricle enlarges to more than 55 millimeters at rest.
• You are going to have another open-heart surgery such as coronary artery bypass graft surgery.

Your doctor may recommend that you have surgery even if you do not have symptoms, because symptoms typically only occur after the condition has progressed to the point that it has already damaged the heart.

If you choose to have aortic valve replacement surgery, you can expect to live to a normal or near-normal life expectancy. There are some risks associated with surgery. But the risk of dying during surgery overall is still reasonably low (5% or less).¹ You may be at higher risk for complications if your left ventricle is working poorly. Surgery may not be recommended in some people who are in extremely poor health.

If you have valve replacement surgery, a mechanical or tissue valve will be used to replace your heart valve. Before you have surgery, you and your doctor will decide on which type of valve is right for you. To help with this decision, see:

Heart valve problems: Should I choose a mechanical valve or tissue valve to replace my heart valve?

Other Places To Get Help

Organizations

Related Information

• Aortic Valve Stenosis
• Chest Problems
• Coronary Artery Disease
• Endocarditis
• Heart Failure

References

Citations

1. Bonow RO, et al. (2006) ACC/AHA 2006 guidelines 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 (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease). Circulation, 114(5): e84–e231.

2. Otto CM, Bonow RO (2008). Aortic regurgitation section of Valvular heart disease. In P Libby et al., eds., Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed., pp. 1635–1646. Philadelphia: Saunders Elsevier.

Other Works Consulted

• Bonow RO, et al. (2008). 2008 Focused update incorporated into the ACC/AHA 2006 Guidelines 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 (Writing committee to revise the 1998 Guidelines for the management of patients with valvular heart disease). Circulation, 118(15): e523–e661.

• Curtin RJ, Griffin BP (2006). Valvular heart disease. In DC Dale, DD Federman, eds., ACP Medicine, section 1, chap. 11. New York: WebMD.

• Hirsch J, et al. (2008). Executive summary: American College of Chest Physicians evidence-based clinical practice guidelines (8th ed.). Chest, 133(6): 71S–109S.

• Nishimura RA, et al. (2008). ACC/AHA 2008 guideline update on valvular heart disease: Focused update on infective endocarditis: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation, 118(8): 887–896.

• Oakley RE, et al. (2008). Choice of prosthetic heart valve in today's practice. Circulation, 117(2): 253–256.

• Rosengart TK, et al. (2008). Percutaneous and minimally invasive valve procedures: A scientific statement from the American Heart Association Council on Cardiovascular Surgery and Anesthesia, Council on Clinical Cardiology, Functional Genomics and Translational Biology Interdisciplinary Working Group, and Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation, 117(13): 1750–1767.

• Smith SC, et al. (2006). AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: Endorsed by the National Heart, Lung, and Blood Institute. Circulation, 113(19): 2363–2372. [Erratum in Circulation, 113(22): 847.]

• Stewart WJ, Carabello BA (2007). Aortic valve disease. In EJ Topol et al., eds., Textbook of Cardiovascular Medicine, 3rd ed., pp. 366–388. Philadelphia: Lippincott Williams and Wilkins.

• Stout KK, Verrier ED (2009). Acute valvular regurgitation. Circulation, 119(25): 3232–3241.

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