Aortic Regurgitation (Aortic Valve Insufficiency)

Aortic regurgitation, also called aortic insufficiency or a leaking aortic valve, means the valve between the heart's main pumping chamber and the aorta does not close fully. After each beat some blood flows back into the left ventricle, which has to handle a larger volume and gradually stretches and thickens to cope.

A mild leak is common and harmless. A severe leak is tolerated for years without symptoms, but if the ventricle is allowed to enlarge too far, the damage may not recover even after the valve is fixed. The purpose of follow-up is to time surgery before that point, guided by echocardiography as well as by how you feel.

Symptoms

• No symptoms for many years in chronic regurgitation
• Breathlessness on exertion, and later when lying flat or at night
• Tiredness and reduced exercise capacity
• Awareness of a forceful heartbeat, particularly lying on the left side
• Palpitations
• Chest pain or tightness on exertion
• Ankle swelling in advanced disease
• Sudden severe breathlessness and collapse when the leak is acute

Causes and risk factors

The leak may come from the valve leaflets or from widening of the aortic root that pulls them apart. Leaflet causes include a bicuspid aortic valve, present from birth in 1 to 2 percent of people, age-related degeneration, rheumatic heart disease, which remains the main cause in many parts of the world, and infective endocarditis. Root causes include long-standing high blood pressure, Marfan syndrome and related connective tissue conditions, and aortitis. Acute severe regurgitation results from endocarditis destroying the valve, aortic dissection or chest trauma, and is a surgical emergency.

How it is diagnosed

• Examination: A blowing murmur heard after the second heart sound, a wide gap between upper and lower blood pressure readings, and a strong bounding pulse.
• Transthoracic echocardiogram: The main test. It grades the leak, shows why the valve leaks, and measures left ventricular size and ejection fraction, which determine timing of surgery.
• Transoesophageal echocardiogram: Gives detail on leaflet anatomy when repair is being considered or endocarditis is suspected.
• Cardiac MRI: Quantifies regurgitant volume and ventricular size when echo is inconclusive.
• CT or MR angiography of the aorta: Measures the aortic root and ascending aorta, as a dilated aorta may need replacement at the same operation.
• ECG, exercise test and coronary assessment: Reveal hidden symptoms and check the coronary arteries before surgery.

Treatment options

• Surveillance: Mild to moderate leaks need an echocardiogram every 1 to 3 years; severe leaks without symptoms every 6 to 12 months.
• Blood pressure control: ACE inhibitors, ARBs or calcium channel blockers when pressure is raised. Medicines do not repair the valve or postpone surgery reliably.
• Surgical aortic valve replacement: The standard treatment for severe regurgitation with symptoms, an ejection fraction of about 55 percent or less, or a markedly enlarged ventricle. Mechanical valves last but need lifelong warfarin; tissue valves avoid warfarin but wear out over 10 to 20 years.
• Aortic valve repair and valve-sparing root surgery: Keeps your own valve in suitable anatomy, performed in centres with specific experience.
• Ross procedure: Your own pulmonary valve is moved to the aortic position. An option for selected younger adults in expert hands.
• Replacement of the aortic root or ascending aorta: Done when the aorta exceeds size thresholds, often together with the valve.
• TAVI: Designed for narrowed, calcified valves. In pure regurgitation it is used only in selected people who cannot have surgery.

When it is urgent

Call local emergency services for sudden severe breathlessness, sudden tearing pain in the chest or back, fainting, or fever with a known valve problem or a new murmur, which may indicate endocarditis. Acute severe aortic regurgitation needs emergency surgery at the nearest cardiac centre and cannot wait for travel.

Travelling to Türkiye for treatment

Chronic aortic regurgitation is slow and predictable, which suits a planned second opinion or a planned operation. Send your echocardiogram images, not only the report, plus any CT of the aorta. For valve surgery expect about 2 to 3 weeks in Istanbul: 5 to 8 days in hospital and a recovery period before you are cleared to fly. Anticoagulation monitoring, cardiac rehabilitation and lifelong echo follow-up must be organised at home beforehand. If you have breathlessness at rest, stabilise locally first.

Send your reports, scans and a short history and a Clinic-Y coordinator replies within 24 hours with suitable teams and written, all-inclusive proposals side by side. Reviewing your case is free.

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