Aortic regurgitation !
Aortic regurgitation is a leak of the aortic valve: after each beat some blood flows backward from the aorta into the left ventricle.
Updated 2026-10-29
Structures involved
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- Aortic right coronary cusp
- Aortic left coronary cusp
- Aortic non-coronary cusp
- Ascending aorta
- Left ventricle
- Valve rings (fibrous skeleton)
- Aortic arch
- Mitral anterior leaflet
In the clinical exam
- Cardiac auscultation: the areas and the order
- Valve murmurs: the table to know
- Dynamic auscultation: Valsalva, squatting, standing and handgrip
- Abnormal pulses: paradoxus, alternans, parvus et tardus, bounding
- Arterial pulse: rate, rhythm and amplitude
In physiology
- The ventricular pressure–volume loop
- Systolic, diastolic, mean and pulse pressure
- Murmurs and the hemodynamics of valve disease
Why it happens
What it is
Backflow of blood from the aorta into the left ventricle during diastole because the aortic valve does not close properly.
Who gets it
Less common than aortic stenosis or mitral regurgitation. Rheumatic disease remains a relevant cause in Colombia and Latin America; elsewhere, bicuspid valves and aortic root dilation predominate.
Causes
- Valve leaflet disease: bicuspid aortic valve, rheumatic heart disease, infective endocarditis
- Aortic root dilation: hypertension, Marfan syndrome, ageing
- Aortic dissection involving the root (acute)
- Inflammatory aortitis: ankylosing spondylitis, tertiary syphilis
Risk factors
- Bicuspid aortic valve
- Previous rheumatic fever
- Long-standing hypertension
- Connective tissue disease
- Infective endocarditis
- Untreated syphilis
Pathophysiology
Regurgitant blood adds to normal filling, creating a combined volume and pressure load. In chronic disease the left ventricle dilates and hypertrophies, keeping output with a large stroke volume, which widens the pulse pressure. Eventually the ventricle fails. In acute disease the ventricle cannot adapt and pulmonary oedema and shock follow.
Classification
- Acute vs chronic
- Leaflet disease vs aortic root disease
- Severity: mild, moderate or severe by echocardiography
Symptoms and signs
- Often no symptoms for many years
- Exertional breathlessness, orthopnoea and fatigue
- Palpitations or awareness of the heartbeat
- Early diastolic decrescendo murmur at the left sternal border, louder sitting forward in expiration
- Wide pulse pressure with a bounding, collapsing (water-hammer) pulse
- Head bobbing and visible arterial pulsations in severe chronic disease
Diagnosis
- Clinical
- Suggested by the diastolic decrescendo murmur and wide pulse pressure; peripheral signs reflect the large stroke volume.
- Tests
- ECG may show left ventricular hypertrophy. Blood cultures if endocarditis is suspected; syphilis serology when relevant.
- Imaging
- Echocardiography confirms the mechanism and severity and measures ventricular size and function and the aortic root. CT or MRI assesses the aorta; CT angiography is urgent if dissection is suspected.
Differential diagnosis
- Pulmonary regurgitation
- Mitral stenosis
- Patent ductus arteriosus
- Aortic dissection
- High-output states such as anaemia or hyperthyroidism
Goal of treatment
Monitor and replace the valve before irreversible left ventricular damage, control blood pressure and treat the aorta and the cause.
Treatment
- Follow-up
- Regular echocardiographic follow-up of ventricular size and function in asymptomatic patients.
- Medical
- Blood pressure control with vasodilators such as ACE inhibitors, ARBs or dihydropyridine calcium channel blockers; heart-failure drug classes when surgery is not possible.
- Surgical
- Aortic valve replacement (or repair) for severe symptomatic disease or ventricular dysfunction or dilation; aortic root surgery when dilated.
- Acute
- Emergency surgery for acute regurgitation, for example from dissection or endocarditis.
Complications
- Heart failure
- Infective endocarditis
- Ventricular arrhythmias
- Aortic dissection in root disease
Prognosis
Chronic aortic regurgitation can stay stable for many years. Once symptoms or ventricular dysfunction appear, outcome worsens without surgery. Acute regurgitation is a surgical emergency.
Test yourself
Think of the answer, then tap the question to see it.
What is the typical murmur of aortic regurgitation?
An early diastolic, high-pitched decrescendo murmur at the left sternal border, best heard sitting forward in full expiration.
Why is the pulse pressure wide in chronic aortic regurgitation?
A large stroke volume raises systolic pressure, while backflow into the ventricle lowers diastolic pressure.
What is a water-hammer (Corrigan) pulse?
A bounding pulse that rises and collapses rapidly, typical of chronic aortic regurgitation.
Which acute cause of aortic regurgitation is a vascular emergency?
Type A aortic dissection extending into the aortic root.
Which two conditions commonly dilate the aortic root and cause regurgitation?
Marfan syndrome and long-standing hypertension; aortitis from syphilis or ankylosing spondylitis is also possible.
Related conditions
- Aortic dissection
- Infective endocarditis
- Rheumatic heart disease
- Aortic Valve Stenosis
- Heart failure
- Syphilis
- Coarctation of the aorta
- Patent ductus arteriosus
Educational information, not medical advice. For any symptom, see a health professional.
Sources: Aortic Insufficiency (StatPearls (NCBI Bookshelf), 2023).
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