Aortic Regurgitation

Introduction
● Aortic regurgitation (AR) is characterized by diastolic reflux of
blood from the aorta to the LV.
● AR may be caused by malfunction of the aortic valve leaflets
themselves, by dilation of the aortic root and annulus, or a
combination of these factors.
● Aortic root disease now accounts for gt50 of all AVRs
● Clinical presentation is highly variable and depends on multiple
factors, including acuity of onset, aortic and LV compliance,
hemodynamic conditions, and severity of the lesion.
Epidemiology
● Incidence of clinically significant AR increases with age
● Typical peak in 4th to 6th decade of life
● More common in men than women
● Overall prevalence of AR was 4.9 in Framingham Heart Study and
10 in Strong Heart Study
● Prevalence of moderate or greater severity was 0.5 and 2.7,
respectively
● Most common cause of AR in developing countries is RHD
● In developed countries the leading cause of AR is either congenital
(particularly due to bicuspid leaflets) or degenerative disease
(including annuloaortic ectasia).
Valve-Related Causes of AR
● Rheumatic disease
● Cusps become fibrotic and retract
(usually also stenotic) MV involved as
well
● Atherosclerotic degeneration
● Infective endocarditis
● Leaflet perforation
● Vegetation interferes with coaptation
● Trauma (chest wall or deceleration
injury)
● Bicuspid aortic valve (can be
associated with aortic root dilation as
well)
● Myxomatous degeneration
● Structural deterioration of
bioprosthesis
● Other less common causes
● Ankylosing spondylitis (can cause
disease of both the leaflets and the
aortic root)
● SLE, RA
● Takayasu disease
● Anorectic drugs
● Membranous subaortic stenosis
Aortic root-related causes of AR
● Idiopathic aortic root dilation
● Aortoannular ectasia
● Marfan syndrome
● Ehlers-Danlos syndrome
● Osteogenesis imperfecta
● Aortic dissection
● Syphilitic aortitis
● Trauma
● Ankylosing spondylitis
● Bicuspid aortic valve with dilated aortic root
Acute Aortic Regurgitation

● Most commonly caused by bacterial endocarditis,aortic dissection,

or blunt chest trauma
● Sudden large regurgitant volume is imposed on an LV of normal
size that has not had time to accommodate the volume overload.
● Abrupt increase in LVEDV leads to rapid and dramatic increase in
LVEDP and LA pressures
● Inability of ventricle to develop compensatory chamber dilatation
acutely results in a decrease in forward stroke volume.
● Tachycardia may develop as a compensatory mechanism to
maintain cardiac output, but often insufficient.
Chronic Aortic Regurgitation
● Chronic AR imposes both volume and pressure overload on the
LV.
● Increased regurgitant volume, increased LVEDV and increased
wall stress
● Increased chamber compliance accommodates increased volume
w/o increasing filling pressures
● Compensatory eccentric hypertrophy also occurs, helping to
maintain normal stroke volume with the chamber enlargement
● LVEDV increases but LV wall compliance prevents increase in
LVEDP
 Pathphysiology

• In contrast to MR, in which a fraction of the LV stroke volume is

ejected into the low-pressure left atrium, in AR the entire LV stroke
volume is ejected into a high- pressure chamber (i.e., the aorta),
although the low aortic diastolic pressure does facilitate ventricular
emptying during early systole
• In MR, especially acute MR, the reduction of wall tension (i.e.,
reduced afterload) allows more complete systolic emptying; in AR the
increase in LV end-diastolic volume (i.e., increased preload) provides
hemodynamic compensation.
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.

Signs and symptoms may include:

● Fatigue and weakness, especially when you increase your activity level
● Shortness of breath with exercise or when you lie down
● Swollen ankles and feet
● 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)