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Regurgitation, Aortic Valve

Definition :
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 blood that was just pumped out of your heart to leak back into it.

The leakage of blood may prevent your heart from efficiently pumping blood out to the rest of your body. If your heart isn't working efficiently, you may feel fatigued and short of breath.

Aortic valve regurgitation can develop suddenly or over decades. It has a variety of causes, such as rheumatic fever. Once aortic valve regurgitation becomes severe, surgery is usually required to repair or replace the aortic valve.

Aortic valve regurgitation is also called aortic insufficiency or aortic incompetence.

Causes:
Aortic valve regurgitation disrupts the way blood normally flows through your heart and its valves.

Your heart, the center of your circulatory system, consists of four chambers. The two upper chambers, the atria, receive blood. The two lower chambers, the ventricles, pump blood to your lungs and to the rest of your body. Blood flows through your heart's chambers, aided by four heart valves. These valves open and

close to let blood flow in only one direction through your heart :

  • Tricuspid valve
  • Pulmonary valve
  • Mitral valve
  • Aortic valve

The aortic valve consists of three tightly fitting, triangular-shaped flaps of tissues called leaflets. These leaflets connect to the aorta through a ring called the annulus.

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 all of the blood has gone through the valve and the left ventricle has relaxed, the leaflets swing closed 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 either to open or close fully. When a valve doesn't close tightly, blood can leak backward. This backward flow through a valve is called regurgitation.

Numerous causes
Any condition that damages a valve can cause regurgitation. Causes of aortic valve regurgitation may be :

  • A congenital heart defect. You may have been born with an aortic valve that has one leaflet (unicuspid valve) or two leaflets (bicuspid valve) rather than the normal three leaflets. This puts you at risk of developing aortic valve regurgitation at some time in your life.
  • Deterioration of the valve with age. The aortic valve opens and shuts tens of thousands of times a day, every day of your life. Aortic valve regurgitation may result from age-related wear and tear on the valve.
  • 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, leading to aortic valve regurgitation later in life. Rheumatic fever may damage more than one heart valve, and in more than one way. A damaged heart valve may not open fully or close completely — or both. Rheumatic fever is still prevalent in underdeveloped countries, and many older adults in the United States were exposed to rheumatic fever as children.
  • Other causes. Other, rarer conditions that can damage the aortic valve and lead to regurgitation include Marfan syndrome (a disease of connective tissue), ankylosing spondylitis (a spine disorder) and syphilis (a sexually transmitted disease). Damage to the aorta near the site of the aortic valve, such as damage from trauma to your chest or from a tear in the aorta, also can cause backward flow of blood through the valve.

Aortic valve regurgitation — of any cause — can weaken your heart. 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. In response, this chamber of your heart may enlarge and thicken. At first these adaptations help the left ventricle pump blood with more force. But eventually these changes weaken the left ventricle — and your heart overall.

Risk factors :
Aortic valve regurgitation is most common in men between the ages of 30 and 60. However, women and those older or younger can be affected too.

Your risk is greater if your aortic valve has already been damaged by some other condition, such as endocarditis or rheumatic fever. You also have an increased risk if you were born with a unicuspid or bicuspid aortic valve. Doctors can detect this condition by listening to heart sounds with a stethoscope and with the aid of medical tests. In addition, anyone with Marfan syndrome, ankylosing spondylitis or syphilis is at risk of developing a leaky aortic valve.

When to seek medical advice :
Take the signs and symptoms of aortic valve regurgitation seriously and see a doctor right away if they develop. Sometimes the first indications of aortic valve regurgitation are those of its major complication, congestive heart failure. Signs and symptoms of congestive heart failure — a serious condition — include fatigue, shortness of breath, and swollen ankles and feet.

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

However, as aortic valve regurgitation progresses, signs and symptoms usually appear and may include :

  • Fatigue and weakness, especially when you increase your activity level
  • Shortness of breath, especially with exertion or when you lie flat
  • Chest pain, discomfort or tightness, often increasing during exercise
  • Fainting
  • Rapid or irregular pulse
  • Heart palpitations — sensations of a rapid, fluttering heartbeat
  • Swollen ankles and feet

Diagnosis:
Identifying aortic valve regurgitation early is important because the condition can worsen with time, and you may need surgery to correct it.

Your doctor may first suspect that you have aortic valve regurgitation during a routine office visit after listening to your heart with a stethoscope and hearing an abnormal heart sound (heart murmur). Blood leaking through the aortic valve makes a distinct sound.

To begin the evaluation of your heart, your doctor will ask you questions about your health, including signs and symptoms, prior tests and history of heart disease in your family. Next your doctor will perform a physical examination that concentrates on your heart.

From this information, your doctor decides what tests you may need in order to make a diagnosis and develop a treatment plan. For testing you may be referred to a cardiologist — a doctor who specializes in the study of the heart and its function.

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 the same time. Common tests doctors use to diagnose aortic valve regurgitation include :

  • Echocardiogram. This test uses sound waves to produce an image of your heart. In an echocardiogram, sound waves are directed at your heart from a wand-like device (transducer) held on your chest. The sound waves bounce off your heart and are reflected back through your chest wall and processed electronically to provide video images of your heart. An echocardiogram helps your doctor get a close look at your aortic valve. A specific type of echocardiogram, a Doppler echocardiogram, may be used. It allows measurements of the volume of blood flowing backward through an aortic valve. This volume is expressed in cubic centimeters per beat.
  • Chest X-ray. With an X-ray of your chest, your doctor can study the size and shape of your heart to determine whether your left ventricle is enlarged — a possible sign of damage to the aortic valve.
  • Electrocardiogram (ECG). In this test, patches with wires (electrodes) are attached to your skin to measure the electrical impulses given off by your heart. Impulses are recorded as waves displayed on a monitor or printed on paper. An ECG can provide clues about whether the left ventricle is enlarged, a problem which can occur with aortic valve regurgitation.
  • Transesophageal echocardiogram. This type of echocardiogram allows an even closer look at your aortic valve. The esophagus, the tube that runs from your throat to your stomach, lies close to your heart. In a traditional echocardiogram, a transducer is moved across your chest to produce the sound waves necessary to create the image of your beating heart. In a transesophageal echocardiogram, a small transducer attached to the end of a tube is inserted down the esophagus. Because the esophagus lies close to your heart, having the transducer there provides a clear picture of your aortic valve and blood flow through it.
  • Exercise tests. Different types of exercise tests help measure your tolerance for activity and check your heart's response to exertion (exercise).
  • Cardiac catheterization. In this procedure, a doctor threads a thin tube (catheter) through a blood vessel in your arm or groin, into your heart. The catheter is used to deliver dye into your heart chambers and the blood vessels of your heart. The dye, appearing on X-ray images as it moves through your heart, gives your doctors detailed information about your heart and heart valves. Specifically, it can show if blood is leaking back from the aorta into the heart's left ventricle. Some catheters used in cardiac catheterization have miniature devices (sensors) at the tips that can measure pressure within heart chambers, such as the left ventricle. Pressure may be increased in the left ventricle with aortic valve regurgitation.

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.

Complications :
Aortic valve regurgitation — or any heart valve problem — puts you at risk of endocarditis. Endocarditis is an infection of the heart's inner lining — the endocardium. This membrane lines the four chambers and four valves of your heart. Typically, this infection involves one of the heart valves, especially if it's already damaged. If the aortic valve is leaky, it's more prone to infection than a healthy valve.

You can develop endocarditis when bacteria from another part of your body spread through your bloodstream and lodge in your heart. If you have aortic valve regurgitation, your doctor may recommend that you take antibiotics before certain dental or medical procedures to decrease the likelihood that bacteria will enter your bloodstream and cause an infection in your heart.

When it's mild, aortic valve regurgitation may never pose a serious threat to your health. But when it's severe, aortic valve regurgitation may lead to congestive heart failure. Congestive heart failure is a serious condition in which your heart is unable to pump sufficient blood to meet your body's needs.

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

If you have aortic valve regurgitation, your doctor will evaluate your heart with regular echocardiograms to determine whether damage to your heart is accelerating.

Observation
Some people, especially those with mild regurgitation, need no specific treatment. However, even if you don't have signs and symptoms with aortic valve regurgitation, schedule regular evaluations with your doctor. Observation isn't the same as ignoring the condition. Actively observing the stability or the progression of the condition is important so that you can receive the right treatment at the right time.

Medications
No medication can eliminate aortic valve regurgitation. However, your doctor may prescribe certain medications to reduce the degree of aortic valve regurgitation, control blood pressure and try to prevent fluid buildup. If you have aortic valve regurgitation, your doctor may recommend that you take antibiotics before certain dental or medical procedures to prevent the heart infection endocarditis.

Surgery
Once signs and symptoms of aortic valve regurgitation develop, you'll usually need surgery. However, if aortic valve regurgitation is weakening your heart, you may need surgery even if you feel well. While the heart is generally adept at counteracting deficiencies caused by a leaky aortic valve, the problem is that if the valve isn't fixed or replaced in time, the strength of your heart may decline so much that it's permanently weakened. You can avoid that by having surgery at the appropriate time.

The overall function of your heart and the amount of regurgitation help to determine when surgery is necessary. Surgical procedures 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. You don't need long-term anticoagulation therapy after a valvuloplasty.
  • Valve replacement. In many cases, the aortic valve has to be replaced to correct aortic valve regurgitation. In valve replacement surgery, the leaky aortic valve is replaced by an artificial (prosthetic) valve. The two types of artificial valves are mechanical and tissue. Mechanical valves are made from metal and are durable, but they carry the risk of blood clots forming on or near the valve. If you have a mechanical valve, you need to use anticoagulant medication for life to prevent blood clots from forming on the valve. Tissue valves generally come from a pig, cow or human-cadaver donor heart. These kinds of valves wear out over time, and you may need another operation to replace the valve. However, an advantage of the tissue valve is that you don't have to use long-term anticoagulation medication. Another type of tissue valve replacement, called an autograft is sometimes possible. An autograft valve replacement uses your own pulmonary valve — another heart valve — to replace your damaged aortic valve.

Aortic valve surgery usually involves open-heart surgery performed with general anesthesia. Your heart is exposed and connected to a heart-lung machine that assumes your breathing and blood circulation during the procedure. Your surgeon then repairs or replaces your leaky aortic valve.

Aortic valve regurgitation can be eliminated with surgery, and you can usually resume normal activities within a few months. The prognosis following surgery is generally good.

Prevention:
One possible way to prevent aortic valve regurgitation is to prevent rheumatic fever. You can do this by making sure you see your doctor when you have a sore throat. Untreated strep throat can develop into rheumatic fever. Fortunately, strep throat is easily treated with antibiotics. Avoiding infections of the blood, including those caused by intravenous drug use, can prevent damage to the aortic valve that leads to aortic valve regurgitation. In addition, taking good care of your teeth helps prevent bloodstream infections that can damage your heart valves.

You may be able to prevent aortic valve regurgitation from high blood pressure by taking care of your cardiovascular system. Getting your blood pressure under control is important because high blood pressure can lead to aortic valve damage and aortic valve regurgitation. High blood pressure can also cause your aorta to stretch out, which pulls the aortic valve leaflets apart and leads to regurgitation.

 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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