Aortic Regurgitation
Definition
Aortic regurgitation (AR) is retrograde blood flow from the aorta into the LV during diastole, due to incompetent aortic valve leaflets and/or dilatation of the aortic root/ascending aorta. Chronic severe AR leads to LV volume overload, progressive LV dilatation, and ultimately LV dysfunction if untreated.
Key Concepts
Epidemiology and Aetiology
- Chronic AR predominantly caused by degenerative changes (high-income countries) or rheumatic disease (low/middle-income countries)
- Chronic pure severe AR more frequent in men; associated with BAV and aortic dilatation in >50% of cases
- Acute AR: usually infective endocarditis or aortic dissection — requires urgent surgical assessment sources/vhd-esc-2025
very high
Evaluation
- Integrative TTE approach (qualitative + semi-quantitative + quantitative) for AR severity; CMR and 3D echo more accurate for LV volumes and LVEF than 2D echo
- Assess at all aortic levels: annulus, sinuses of Valsalva, sinotubular junction, and ascending aorta
- High BP leads to overestimation of regurgitant volume — assess under controlled BP conditions
- Strain imaging detects subclinical LV dysfunction before thresholds for intervention are reached
- Aortic phenotype (root vs ascending vs mixed) determines suitability for VSARR or AV repair sources/vhd-esc-2025
very high
Medical Therapy
- ACE-I or dihydropyridine calcium channel blockers: symptomatic improvement in chronic severe AR if surgery not feasible; not recommended to delay surgery in asymptomatic patients
- Beta-blockers increase diastolic filling time and thus RVol — use with caution; acceptable post-operatively for HF or rate control
- No medical therapy has been shown to delay surgery in asymptomatic AR sources/vhd-esc-2025
very high
Indications for Intervention — Surgical
- Class I:
- Symptomatic severe AR regardless of LV function
- Asymptomatic severe AR with LVESD >50 mm or LVESDi >25 mm/m² (especially small BSA <1.68 m²) or LVEF ≤50%
- Symptomatic or asymptomatic severe AR undergoing CABG or ascending aorta surgery
- Class IIa:
- AV repair at experienced centres when durable results expected (preferred over replacement in young patients with suitable anatomy)
- Replacement of aortic root/ascending aorta ≥45 mm when AV surgery is already indicated at low risk
- Class IIb (new 2025):
- Surgery for asymptomatic AR with LVESDi >22 mm/m² or LVESVi >45 mL/m² or LVEF ≤55% at low surgical risk
- TAVI for symptomatic severe AR in patients ineligible for surgery if anatomy suitable sources/vhd-esc-2025
very high
Surgical Techniques
- VSARR (valve-sparing aortic root replacement): preferred over Bentall (composite graft) in young patients with root dilatation, good cusp tissue quality, and at experienced centres — superior long-term mortality and lower morbidity (thromboembolism, endocarditis)
- AV repair increasingly performed at experienced centres — better results in symmetric BAV phenotypes
- Ross procedure (pulmonary autograft) is an option in selected young patients at expert centres
- TAVI for AR (Class IIb, new 2025): off-label non-dedicated devices carry ~10% risk of second valve/surgical conversion; dedicated TAVI devices reduce migration and residual AR but associated with high pacemaker rate (~24%) sources/vhd-esc-2025
very high
Aortic Dilatation Management
- Surgery recommended for maximal aortic root/ascending diameter ≥55 mm; ≥50 mm in selected low-risk patients with additional risk factors
- If AV surgery already indicated: concomitant aortic root/ascending surgery at ≥45 mm diameter
- BAV: threshold of 45 mm; consider patient height and intraoperative wall findings
- Marfan syndrome and connective tissue disease: lifelong surveillance after repair for residual aortic segments; screen first-degree relatives sources/vhd-esc-2025
very high
Follow-up
- Asymptomatic severe AR: yearly clinical + echo follow-up; every 3–6 months if approaching thresholds or progressive LV changes
- BNP, CMR, and strain imaging helpful for detecting early LV damage
- Moderate AR: yearly follow-up, echo every 2 years
- Ascending aorta >45 mm: confirm with CCT/CMR at baseline, repeat TTE at 6 months, then yearly; CT/CMR if increase >3 mm sources/vhd-esc-2025
very high
Contradictions / Open Questions
- Optimal volumetric thresholds for surgery in asymptomatic AR (LVESDi vs LVESVi vs LVEF ≤55%) are based on observational data; CMR-based LVESVi 43 mL/m² recently proposed but not prospectively validated
- TAVI for AR: limited RCT evidence; dedicated device data promising but small; high pacemaker rate is a concern
- Role of physical activity restriction in asymptomatic AR with aortic dilatation: current recommendations conservative but data limited
Connections
- Related to concepts/Valvular-Heart-Disease
- Related to concepts/TAVI
- Related to concepts/Aortic-Stenosis
- Related to entities/Atrial-Fibrillation