Aortic valve regurgitation

Aortic valve regurgitation — or aortic regurgitation — is a condition that occurs when your heart’s aortic valve doesn’t close tightly. Aortic valve regurgitation allows some of the blood that was just pumped out of your heart’s main pumping chamber (left ventricle) to leak back into it.

The leakage may prevent your heart from efficiently pumping blood to the rest of your body. As a result, you may feel fatigued and short of breath.

Aortic valve regurgitation can develop suddenly or over decades. Once aortic valve regurgitation becomes severe, surgery is often required to repair or replace the aortic valve.

Most often, aortic valve regurgitation develops gradually, and your heart compensates for the problem. You may have no signs or symptoms for years, and you may even be unaware that you have the condition.

However, as aortic valve regurgitation worsens, signs and symptoms may include:

• Fatigue and weakness, especially when you increase your activity level
• Shortness of breath with exertion or when you lie down
• Swollen ankles and feet (edema)
• Chest pain (angina), discomfort or tightness, often increasing during exercise
• Lightheadedness or fainting
• Irregular pulse (arrhythmia)
• Heart murmur
• Sensations of a rapid, fluttering heartbeat (palpitations)

When to see a doctor

Contact your doctor right away if signs and symptoms of aortic valve regurgitation develop. Sometimes the first indications of aortic valve regurgitation are those of its major complication, congestive heart failure. See your doctor if you have fatigue, shortness of breath, and swollen ankles and feet.

Any condition that damages a valve can cause regurgitation. Causes of aortic valve regurgitation include:

• Congenital heart valve disease. You may have been born with an aortic valve that has only two leaflets (bicuspid valve) or fused leaflets rather than the normal three separate leaflets. This puts you at risk of developing aortic valve regurgitation at some time in your life.
• 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. Rheumatic fever is still prevalent in developing countries but rare in the United States. Many older adults in the United States were exposed to rheumatic fever as children, although they may not have developed rheumatic heart disease.
• Disease. Other rare conditions can enlarge the aortic valve and lead to regurgitation, including Marfan syndrome, a connective tissue disease.
• Trauma. Damage to the aorta near the site of the aortic valve, such as damage from injury to your chest or from a tear in the aorta, also can cause backward flow of blood through the valve.

How your heart works

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 the blood has gone through the valve and the left ventricle has relaxed, the leaflets close 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.

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, possibly causing it to enlarge and thicken.

At first, left ventricle enlargement helps because it maintains adequate blood flow with more force. But eventually these changes weaken the left ventricle — and your heart overall.

Your risk of aortic valve regurgitation is greater if you’ve been affected by any of the following:

• Aortic valve damage. Inflammation associated with certain conditions, such as endocarditis or rheumatic fever, can damage your aortic valve. Also, a narrowing of the aortic valve (aortic stenosis) can be associated with leaking.
• High blood pressure (hypertension). High blood pressure may stretch the root of the aorta where the aortic valve sits. The valve leaflets may no longer meet, resulting in leakage.
• Congenital heart valve disease. If you were born with a malformed aortic valve, your chances of having aortic valve regurgitation increase.
• Disease. Certain conditions, including Marfan syndrome and ankylosing spondylits, may cause the aortic root (where the aorta attaches to the ventricle) to widen, resulting in a leaky aortic valve.
• Age. By middle age, you can develop some aortic valve regurgitation caused by natural deterioration of the valve.

Any heart valve problem puts you at risk of an infection of the heart’s inner lining (endocarditis). If the aortic valve is leaky, it’s more prone to infection than is a healthy valve.

When it’s mild, aortic valve regurgitation may never cause a serious threat to your health. But when it’s severe, aortic valve regurgitation may lead to heart failure. Heart failure is a serious condition in which your heart is unable to pump enough blood to meet your body’s needs.

You’re likely to start by seeing your family doctor. After your initial appointment, your doctor may refer you to a doctor who specializes in the diagnosis and treatment of heart conditions (cardiologist).

Here’s some information to help you prepare for your appointment.

What you can do

• Write down your symptoms and how long you’ve had them.
• Make a list of your key medical information, including other recent health problems you’ve had and all prescription and over-the-counter medications and supplements you’re taking.
• Take a family member or friend with you to the appointment, if possible. Someone who accompanies you can help remember what the doctor says.
• Write down questions to ask your doctor.

For aortic valve regurgitation, questions to ask your doctor include:

• What is likely causing my symptoms?
• Are there any other possible causes?
• What tests do I need?
• What treatment approach do you recommend?
• What are the alternatives to the approach you’re recommending?
• Will I need surgery? If so, what surgeon do you recommend for aortic valve surgery?
• I have other health conditions. How can I best manage them together?
• Are there restrictions I need to follow?
• Should I see a specialist?

Don’t hesitate to ask other questions, as well.

What to expect from your doctor

Your doctor is likely to ask you a number of questions, including:

• When did your symptoms begin?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?
• Do you have heart disease in your family?

Your doctor will ask about your and your family’s medical history and give you a physical exam that includes listening to your heart with a stethoscope. Aortic valve regurgitation usually produces a heart murmur, the sound of blood leaking backward through the aortic valve.

Your doctor will then decide what tests are needed to make a diagnosis. For testing, you may be referred to a cardiologist.

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 at once. Common tests doctors use to diagnose aortic valve regurgitation include:

• Echocardiogram. Sound waves directed at your heart from a wand-like device (transducer) held on your chest produces video images of your heart in motion. An echocardiogram can identify aortic valve regurgitation and determine its severity.
• Exercise tests. Different types of exercise tests help measure your tolerance for activity and check your heart’s response to exertion.
• Cardiac magnetic resonance imaging. Using a magnetic field and radio waves, this test produces detailed pictures of your heart, including the aortic root.
• Electrocardiogram (ECG). Wires (electrodes) attached to adhesive pads on your skin measure electrical impulses from your heart, providing information about your heart rhythm. You might walk on a treadmill or pedal a stationary bike during an ECG to see how your heart responds to exertion.
• Chest X-ray. This enables your doctor to determine whether your heart is enlarged — a possible indicator of aortic valve regurgitation — and the condition of your lungs.
• Cardiac catheterization. When noninvasive tests are inconclusive, this invasive technique provides a more detailed picture of your heart. It involves threading a thin tube (catheter) through a blood vessel in your arm or groin to an artery in your heart and injecting dye through the catheter to make the artery visible on an X-ray.

These tests help your doctors diagnose aortic valve regurgitation, determine how serious the problem is, and decide whether your aortic valve needs repair or replacement.

Treatment of aortic valve regurgitation depends on how severe your regurgitation is, your signs and symptoms, and whether the regurgitation is affecting your heart function.

Observation

Some people, especially those with mild regurgitation, may not need treatment. However, the condition may require monitoring by your doctor. You may need regular evaluations, with the frequency depending on how severe your condition is.

Surgery

Your aortic valve may need surgical repair or replacement, even if it’s not causing symptoms. While the heart is generally good at counteracting problems caused by a leaky aortic valve, if the valve isn’t fixed or replaced in time, your heart may weaken permanently.

Heart valve surgery should be done at a high-volume heart valve surgery center with a reputation of excellence, and cardiologists, imaging specialists and cardiac surgeons with experience in treating heart valve conditions.

Discuss the risks and benefits of surgery with your doctor. Your surgery options 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.
• Valve replacement. In many cases, the aortic valve has to be replaced with a mechanical valve or a tissue valve. Mechanical valves, made from metal, are durable, but carry the risk of blood clots forming. If you receive a mechanical aortic valve, you’ll need to take an anticoagulant medication, such as warfarin (Coumadin), for life to prevent blood clots.

  Tissue valves — which may come from a pig, cow or human cadaver donor — often eventually need replacement. Another type of tissue valve replacement that uses your own pulmonary valve (autograft) is sometimes possible.

Less invasive techniques

Aortic valve replacement generally requires open-heart surgery under general anesthesia and with the use of a heart-lung bypass machine. Less invasive surgical techniques, such as using a small, lighted tube through a small incision to see the surgical area (laparoscopy), are being explored for aortic valve surgery.

Minimally invasive cardiac surgery is associated with less pain, a shorter hospital stay and fewer complications. However, the surgery is more complex than open-heart surgery, partly because the surgeon can’t see the valve as well. Talk to your surgeon to see if this type of surgery might be right for you.

To improve your quality of life, your doctor may recommend that you:

• Control high blood pressure. Lowering blood pressure reduces the strain on your aortic root. Cutting back on salt helps you maintain your blood pressure within a normal range.
• Eat a heart-healthy diet. Food doesn’t directly affect aortic valve regurgitation, but a healthy diet can help prevent other heart disease that can weaken the heart muscle. Eat foods low in saturated and trans fats, sugar, salt and refined grains, such as white bread. Eat a variety of vegetables and fruits, whole grains, and proteins, such as lean meats, fish and nuts.
• Maintain a healthy weight. Keep your weight within a range recommended by your doctor.
• Exercise. How long and hard you’re able to exercise depends on the severity of your condition and the intensity of exercise. Ask your doctor for guidance before starting to exercise, especially if you’re considering competitive sports.
• 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 with your doctor before you become pregnant. Pregnancy causes your heart to work harder. How a heart with aortic valve regurgitation tolerates this extra work depends on the degree of leakage and how well your heart pumps. Throughout your pregnancy and after delivery, your cardiologist and obstetrician should monitor you.

For any heart condition, see your doctor regularly so he or she can monitor you and possibly catch aortic valve regurgitation before it develops or in the early stages, when it’s more easily treatable. Also, be aware of conditions that contribute to developing aortic valve regurgitation, including:

• Rheumatic fever. If you have a severe sore throat, see a doctor. Untreated strep throat can lead to rheumatic fever. Fortunately, strep throat is easily treated with antibiotics.
• High blood pressure. Check your blood pressure regularly. Make sure it’s well-controlled to prevent aortic regurgitation.

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