What is aortic regurgitation?
Aortic regurgitation (AR), also known as aortic valve regurgitation, occurs when the heart’s aortic valve does not properly close. When the valve doesn’t close tightly, some of the blood that was pumped out of the heart’s main chamber (left ventricle, or LV) can leak back into it. Since the heart is unable to efficiently pump blood to the rest of the body, people suffering from aortic regurgitation may feel fatigued and have shortness of breath. This heart condition can develop suddenly or over several years, but once it becomes severe, surgery is usually required to replace or repair the aortic valve.
Prevalence of aortic regurgitation
The most common cause of prolonged or chronic aortic regurgitation was previously rheumatic heart disease, but recent evidence has revealed it is mostly linked to bacterial endocarditis. About 75 percent of patients with this condition in its severe stages survive five years after diagnosis, while 50 percent survive for 10 years. Those with milder cases survive 10 years in 80–95 percent of cases. In the United States, the age of expectation for those suffering from congenital and degenerative valve abnormalities leading to AR peaks at 40–60 years. Internationally, the prevalence of AR is not well known, however, rheumatic heart disease is very common in many countries within Asia, the Middle East, and North Africa.
There appear to be no major distinctions between racial populations in the United States in terms of the prevalence of AR. It is, however, seen more commonly in men than in women. Statistics from the Framingham study found that AR was seen in 13 percent of the male population, and 8.5 percent of the female population. Chronic cases of the illness often begin in patients in their late 50s and older. Generally speaking, chronic AR is not prevalent before the age of 70.
What causes aortic insufficiency?
What causes aortic regurgitation or aortic insufficiency? Before getting into the aortic valve regurgitation causes, here’s some important information about how the heart works. The human heart has four valves that allow blood to flow in the proper direction: the mitral valve, tricuspid valve, pulmonary valve, and aortic valve. Each has flaps that open and close once during each heartbeat, but in an unhealthy heart, these valves do not open or close properly. When this happens, the blood flow to and from the heart is disrupted.
Specifically with AR, the valve connecting the lower left heart chamber (left ventricle) and the main artery that leads to the body (aorta) doesn’t close as it should. As a result, blood leaks backward into the left ventricle, forcing it to hold too much blood, and causing it to thicken and enlarge. At first, the left ventricle enlargement assists, as it maintains enough blood flow with greater force. But over time, this change will weaken the left ventricle, and eventually harm your entire heart. Here are some of the common causes of AR:
Congenital heart valve disease: This term is used to describe people born with an aortic valve with only two cusps (bicuspid valve), or fused cusps, instead of three separate ones. These defects put you at risk of developing AR at some time in your later life.
Age-related changes: Symptoms of aging such as the buildup of calcium deposits on the aortic valve can cause the cusps to stiffen. This can lead to the narrowing of the valve, and if it is unable to close properly, it may lead to AR.
Endocarditis: Endocarditis is defined as an infection of the heart that involves the heart valves. This condition can damage the aortic valve, leading to AR.
Rheumatic fever: Defined as a complication of strep throat, rheumatic fever can damage the aortic valve. This illness is still prevalent in developing countries but has become a rare condition in the United States. Some older adults were exposed to the illness as children, but they may not have developed rheumatic heart disease.
Aortic valve stenosis: When the aortic valve is unable to open all the way because of stiffening or thickening, this is known as aortic valve stenosis. In these cases, the valve has great difficulty closing the right way, causing AR.
Trauma: Damage to the aorta near the aortic valve can cause backward flow of blood through the valve.
Other diseases: There are other rare conditions that can enlarge the aorta and its valve and cause aortic regurgitation. These conditions include Marfan syndrome, Ehlers-Danlos syndrome, and autoimmune conditions such as lupus. Additionally, the following illnesses may also lead to AR: bicuspid aortic valve, ankylosing spondylitis, Behcet disease, giant cell arthritis, rheumatoid arthritis, systemic lupus erythematosus, Takayasu arteritis, and Whipple disease.
Risk factors of AR include older age, congenital heart conditions, a history of heart infections, other heart valve conditions, and high blood pressure. Aortic valve regurgitation can cause several health complications, which include heart failure, infections that damage the heart, heart rhythm abnormalities, and even death.
Symptoms of aortic regurgitation
Aortic valve regurgitation generally develops over time, and the heart compensates for the problems associated with it. It may take years before aortic regurgitation signs and symptoms begin to appear, and many people are completely unaware that they have the condition. As the condition worsens gradually, the following signs and symptoms may present themselves:
- Weakness and fatigue, especially when activity increases
- Shortness of breath when exercising or lying down
- Swollen feet and ankles
- Chest pain (angina), discomfort, or tightness increasing during physical activity
- Lightheadedness or fainting
- Irregular pulse (arrhythmia)
- Heart murmur
- Heart palpitations
If any of these signs and symptoms are present, you should see your healthcare practitioner as soon as possible.
Stages of aortic regurgitation
There are four stages of aortic regurgitation:
Stage A: Patients with bicuspid aortic valve, a history of infection on the valve, rheumatic heart disease, and those born with congenital abnormalities in the valve are at a higher risk of developing AR. At this stage, they do not have the condition yet.
Stage B: The patients in this category have mild or moderate AR. Their heart functions normally, there are no symptoms, and the heart is not significantly enlarged.
Stage C: These patients are still void of symptoms; however, the aortic valve is severely leaky. The heart is still pumping relatively normally, but there is clear evidence of enlargements.
Stage D: In this final stage, patients have a severely leaky aortic valve and other noticeable symptoms. The heart is significantly enlarged and symptoms like shortness of breath, swelling, and fatigue are present. Physical activity enhances these symptoms.
Diagnosis of aortic regurgitation
If you noticed any of the aforementioned symptoms and seek a diagnosis, your doctor may review the signs and symptoms, discuss you and your family’s medical history, and perform a physical examination. Healthcare professionals may listen to your heart using a stethoscope to determine if you have a heart murmur, which may be a sign of an aortic valve condition. If your doctor has good reason to believe you may need additional testing, he may recommend you to a cardiologist for a more thorough evaluation. Here’s what these tests include:
Echocardiogram: An echocardiogram transmits sound waves at your heart from a wand-like device known as a transducer. It is held to your chest to produce video images of your heart in motion. The test helps specialists get a better look at the condition of the aortic valve and the aorta and allows them to determine the cause and severity of your condition. It will also reveal any additional heart valve conditions you may have.
Electrocardiogram (ECG): In an electrocardiogram, wires (electrodes) attached to pads on your skin measure the electrical activity and movement of your heart. This test can detect enlarged chambers of your heart, abnormal heart rhythms, and heart disease.
Chest X-ray: X-rays allow doctors to see whether or not your heart is enlarged. This is a possible indicator of AR. This test can also help doctors determine the condition of your aorta and lungs.
Exercise and stress tests: These tests allow doctors to see if you have symptoms of AR during physical activity, as well as the severity of your condition. If you are unable to perform the exercises, medications that provide similar effects to exercise on your heart may be used.
Cardiac magnetic resonance imaging (MRI): Using a magnetic field and radio waves, a cardiac MRI creates detailed images of your heart, including the aorta and aortic valve. The test is typically used to determine the severity of your AR.
Cardiac characterization: This test is not normally used to diagnose AR, but it can be used if the other tests are unable to gain accurate information on the diagnosis or determine the severity of your condition. Doctors may conduct this test before valve replacement surgery to see if anything is obstructing the coronary arteries so that they can be repaired during the valve surgery. To perform this test, a doctor threads a thin tube known as a catheter through a blood vessel in your arm or groin to an artery in your heart. Then, a dye is injected through to make the artery visible on an X-ray. The doctor will then be able to see a more detailed image of your heart arteries and how it functions. The test can also measure the pressure inside the chambers of the heart.
Cardiac pool scan: This test measures how well the left ventricle of the heart is pumping and how much blood is pumped out of the chamber at each heartbeat.
Depending on the severity of your AR, you may need to have an echocardiogram more often. Mild cases need to be tested every three to five years, moderate cases should be examined every one to two years, and for those with severe AR, they should be tested every six to 12 months.
Differential diagnosis of aortic regurgitation
There are some specific things to consider when confirming a diagnosis of aortic regurgitation. For example, an enlarged ascending aorta can stretch the aortic valve annulus and lead to AR without actually damaging the valve leaflets. This may be conflicting for diagnosing the condition, as the causes of AR typically involve damage to the aortic valve leaflets. Another cause of AR includes the dilation of the aortic root. Hypertension can cause the dilation of the aortic root, but it may not be a cause of AR.
It is also important to note that competing diagnoses can mimic aortic regurgitation. For example, diastolic murmurs are not only heard in AR patients. Not every aortic regurgitation murmur signifies the condition.
How to treat aortic regurgitation
The treatment of aortic regurgitation depends on how severe the condition is per patient, whether they are experiencing signs and symptoms, and if the condition is worsening. Patients with mild symptoms or who have none can simply be monitored by their doctor with regular follow-up appointments. The doctor may recommend healthy lifestyle changes and medications that may help treat your symptoms and reduce your risk of experiencing complications.
Some patients may even require surgery to repair or replace the damaged aortic valve, and in other patients, the doctor may recommend surgery even if symptoms have not begun to show. If you are already scheduled for a heart surgery, the doctor may at that time perform aortic valve surgery. You may need a section of the aorta repaired or replaced the same time as the aortic valve surgery if the aorta has expanded. The surgery has traditionally been performed through an incision in the chest, but in some cases, doctors may perform minimally invasive heart surgery that involves much smaller cuts.
The aortic valve replacement surgery is often needed to treat AR. The surgeon will remove the diseased valve and replace it with a mechanical one, or one made from cow, pig, or human heart tissue. Another type of this surgery uses your own pulmonary valve to replace the aortic valve. The disadvantage of using biological tissue is that it degenerates with time and may need to be replaced again. Mechanical valves also bring a disadvantage: patients with mechanical replacement may need to take blood-thinning medications for life to prevent blood clots.
Before your appointment with your doctor, you should write down the symptoms you are noticing and how long you’ve had them. Then, make a list of your key medical information, including other health problems you have had in the past and your medications or supplements you are taking. When you go to your appointment, consider taking a family member or friends along so they can help you remember what the doctor says. It is also a good idea to prepare questions for your doctor before your appointment. Here are some questions you should ask:
- What might be causing my symptoms?
- Are there any other possible causes?
- What tests do I need to undergo?
- What treatment approach would you recommend?
- What are some alternatives to the approach that you’re recommending?
- Will I need surgery? If so, what surgeon do you recommend for aortic valve surgery?
- I have other health conditions. How can I best manage them and my AR together?
- Are there restrictions I need to follow?
- Should I see a specialist?
Home remedies for aortic regurgitation
Fortifying your cardiovascular system is important, whether or not you have any medical or health conditions. However, if you have been diagnosed with AR or some form of heart disease, boosting your heart health is vital. Sedentary lifestyles weaken and diminish the heart’s ability to circulate blood efficiently, and exercise for aortic valve regurgitation is extremely important in maintaining good heart health. If your doctor recommends lifestyle changes and home remedies to treat symptoms and the condition, here are some of the healthy habits you may need to implement:
- Eat a heart-healthy diet rich in fruits and vegetables, low-fat, or fat-free dairy, poultry, fish, and whole grains. You should avoid saturated and trans-fat as well as excess sugar and salt.
- Maintain a healthy weight by managing your eating habits and lifestyle.
- Get regular physical activity, whether that means signing up for a gym membership and attending fitness classes or including 30 minutes of brisk walking or jogging into your daily routine. Before beginning an exercise routine, ask your doctor for guidance. This is especially important if you are considering competitive sports, which may be more physically demanding and stressful.
- Manage stress by trying relaxation activities, meditation, and spending quality time with family and friends.
- Avoid tobacco, and if you smoke, quit as soon as possible. If you need smoking cessation tips and support, speak to your doctor or join a support and accountability group.
- Control high blood pressure by taking medication, changing your diet, and adding light exercise to your daily routine.
Taking a brisk walk may help strengthen your body’s circulatory system, but other forms of exercise may be risky to your health. For example, lifting heavy objects can strain your heart, and if you have aortic stenosis, extreme exercise can actually overexert your heart and lead to chest pains and fainting spells. The bad news is that exercise won’t reverse your condition, but it will lower your blood pressure, strengthen your heart to help it recover faster after surgery, and improve your symptoms. It can help you lose weight, which will further release the burden on your heart health. It is very important that you abide by your doctor’s instructions, as they will be catered to your specific diagnosis.
Tips for aortic regurgitation patients
If you have been diagnosed with aortic regurgitation, there are lifestyle and health changes you can make to improving the quality of your life. Here are some tips for how you can take care of yourself better from now onwards:
- See your doctor immediately if you have new symptoms, or if the symptoms that you already have get worse. These symptoms may include chest pain or chest pressure, fainting, and shortness of breath. If you experience these signs, it is likely that you may need surgery.
- If your AR is severe, your doctor will probably recommend that you avoid strenuous physical activity. If exercise is an important part of your life, talk to your doctor about what kind of physical activity is safe for you to do.
- Especially if you have severe AR, you should be seeing your doctor regularly. Make sure that you get all the tests that you need to assess your heart health.
- Stay on top of managing your other health problems, including high blood pressure, diabetes, and high cholesterol.
- You should also practice good dental hygiene, and have regular checkups with your dental hygienist. Good dental health is very important, as bad bacteria can spread from infected teeth and gums into the valves of your heart.
- Maintain a healthy immune system by getting your annual flu vaccine. You should also get a pneumococcal vaccine shot, and if you have had one before, find out from your doctor if you need an updated dose.
- Speak with your doctor or healthcare provider if you have any concerns about physical activity and your heart. If you are concerned if you can have sex or not, ask your doctor.
Prognosis and life expectancy of aortic valve regurgitation
Aortic stenosis is prevalent in approximately one to two percent of people over 65 years, and four percent of people over 85. It accounts for the vast majority of aortic valve disease cases. Managing the stenosis has been based on the severity of the condition, age of the patient, the presence of comorbidities, and their operative risk. Treatment for aortic regurgitation is generally only necessary when the stenosis is severe and when patients are asymptomatic. The onset of symptoms is a poor prognostic indicator without valve replacement. Over half of the patients will die within the next 12 to 18 months of symptom onset, unless the valve is replaced. To maintain the quality of life and extend the aortic valve regurgitation life expectancy, regular visits to the doctor and proper testing is paramount.
Severe acute aortic valve regurgitation has a very high short-term rate of morbidity and mortality. In most cases, early surgical intervention is required. Severe chronic aortic regurgitation follows a more gradual clinical course. However, when symptoms begin to show up and worsen, the patient’s clinical status May begin to deteriorate very rapidly. Surgical intervention is extremely important before symptoms develop, and this is why it is important to maintain good heart health and take all necessary precautions and tests early on. With conservative medical management of severe chronic AR, the following estimates apply:
- Death from any cause: 4.7 percent
- Congestive heart failure: 6.2 percent
- Aortic valve surgery 14.6 percent
Multiple studies have revealed that the most important predictors of mortality are not symptoms, but left ventricle (LV) ejection fraction, and LV end-systolic dimension.
Aortic valve regurgitation, specifically aortic stenosis, is a very common valvular heart disease in the western world. It increases in prevalence as the population ages, and the onset of symptoms is a poor prognostic sign. Patients who suffer from AR should be closely monitored and should be treated with a replacement surgery, if appropriate. Unfortunately, while the surgery offers excellent results for patients with symptomatic severe aortic stenosis, those who are not suitable surgical candidates have a poor survival rate. There have been major advances in cardiac surgery, which has allowed elderly patients to undergo aortic valve replacement and extend their life expectancy.
If left untreated, symptomatic severe aortic stenosis leads to a significant increase in mortality, and a decrease in survival rate and quality of life. Aortic valve replacement surgery results in improved survival rates, and a better quality of life. Patients who do not have symptoms should still be carefully monitored objectively, to take a proactive approach to the development of symptoms, and so they can get really referral for surgery to extend their lives.