Aortic Valve Regurgitation: Causes, Symptoms & Treatment

Aortic valve insufficiency refers to an insufficiency of the aortic valve in the left ventricle of the heart. Some of the aortic blood may flow back during the relaxation phase of the chamber, with significant long-term effects on the heart and overall cardiovascular system, depending on the severity.

What is aortic valve regurgitation?

Leakage of the aortic valve, which acts as a valve between the left ventricle and the aorta, the body’s main artery, is called aortic insufficiency or, better, aortic valve regurgitation. During the systolic contraction phase of the ventricle, the aortic valve opens and gives way to oxygenated blood from the pulmonary circulation. The aortic valve is designed as a so-called pocket valve with three pockets that fill with blood after the end of the pressure phase and virtually close the aorta, so that no blood can flow back from the aorta into the left ventricle during the relaxation phase of the chambers (diastole). If the aortic valve does not close completely and more than 15% of the blood pumped into the aorta flows back, aortic valve insufficiency is present.

Causes

The most common cause of aortic valve regurgitation is a direct bacterial infection of the valve tissue (endocarditis) or a preceding streptococcal infection, which can cause rheumatic fever and spread to the heart valves. An infection that has been overcome can lead to scarring of the pockets of the aortic valve, preventing it from closing tightly. A serious problem in the past was the venereal disease syphilis, which can also spread to the heart valve tissue and cause valve insufficiencies. Despite the possibility of treatment with antibiotics, the disease is on the rise again. In rarer cases, certain gene mutations also play a role, as in Marfan syndrome. The gene mutations, which occur spontaneously in up to 40 percent of cases, i.e. in this case they are not inherited, lead to disorders in the structure of the connective tissue. In some cases, a malposition of the aortic valve plays a role. It can happen that only two pockets instead of three pockets are formed in the aortic valve, which is not noticeable at first, but promotes later insufficiency. Other factors include overstretching of the aortic root or ascending branch of the aorta, or aortic dissection, in which the inner wall of the aorta becomes dislodged and blood enters the interstitial space between the aortic walls.

Symptoms, complaints, and signs

Mild forms of aortic valve regurgitation, in which blood regurgitation accounts for less than 20 percent of the blood squeezed out of the left ventricle, are virtually asymptomatic and are not noticed by the affected person. In more severe forms of insufficiency, there is initially a high blood pressure amplitude with usually very low diastolic pressure. The next signs that aortic valve insufficiency may be present are noticeable physical performance deficits with increasing shortness of breath and cardiac arrhythmias, which can trigger occasional fainting spells. If the insufficiency persists over a long period of time, congestion gradually builds up in the lungs and veins. This leads to water retention in the body tissues and especially in the legs. Further symptoms are a so-called water hammer pulse, a rapid strongly perceptible pulse, which is based on very high blood pressure amplitudes of sometimes over 100 mmHg. In most cases, extrasystoles are also noticeable. In untreated aortic valve regurgitation, an unconscious nodding of the head in rhythm with the pulse may occur.

Diagnosis and course

A number of diagnostic modalities exist for the detection of aortic valve regurgitation. The first tool of choice is auscultation, because the insufficiency is manifested by a typical diastolic murmur (Austin-Flint murmur). This is a rumbling sound that is clearly audible from about mid-diastole to the onset of systole. Other diagnostic options include ECG, ultrasound, phonocardiography, x-ray, and cardiac catheterization. If left untreated, insufficiency can gradually lead to expansion (dilation) of the left ventricle and thickening of the outer heart muscle (eccentric hypertrophy). These physiological compensatory actions cause an increased oxygen demand of the heart muscle and decreasing performance, so that heart failure develops.If left untreated, the progression of the disease can lead to life-threatening conditions via physical decline in performance and gradual changes in the left ventricle along with heart muscles.

Complications

Complications that arise because of untreated aortic valve regurgitation are due to an inadequate supply of oxygenated arterial blood to the entire body. This includes the central nervous system. Due to the leakage of the aortic valve, some of the blood that was pumped from the left ventricle into the aorta during systole flows back during diastole. As a result, it mixes with blood that also flows into the left ventricle from the left atrium during this phase. The accompanying complications depend very much on the degree of leakage or the amount of backflow of blood. If the backflow is less than 20 percent of the original volume squeezed out, there are hardly any symptoms or complications. In the case of higher-grade insufficiencies, complications such as reduced performance, shortness of breath, brief fainting spells after exertion, and frequently also cardiac arrhythmias in the form of frequent extrasystoles or atrial fibrillation occur. If aortic valve insufficiency is more severe and persists for a longer period of time, further complications may arise. The left ventricle may dilate and, because the heart wants to compensate for the reduced supply, a gradual thickening of the ventricular muscles of the left ventricle sets in. The compensatory action ultimately leads to heart failure, which in turn can cause further complications such as water retention in the lower extremities and severe loss of power, as well as venous congestion. The life-threatening conditions that develop as the disease progresses can be largely avoided with early treatment.

When should you see a doctor?

In the worst case, aortic valve insufficiency can lead to the death of the patient and should therefore never be left untreated. The symptoms are not felt directly in the heart, but are usually manifested by other limitations in everyday life. As a rule, these are not particularly characteristic of the disease. However, a doctor should always be consulted in the event of heart complaints or a feeling of weakness. Especially at the onset of respiratory distress, a medical examination is necessary. If the affected person also suffers from loss of consciousness and an increased pulse, these complaints may also indicate aortic valve insufficiency and should be examined. Complaints of the heart not infrequently lead to accumulations of water in various regions of the body. Therefore, if the patient notices these accumulations, a physician must also be consulted to prevent subsequent damage or death of the patient. An unconscious nodding of the head also indicates aortic valve insufficiency in many cases. A medical examination is also definitely required in cases of general fatigue, lassitude, and decreased exercise capacity that occurs for no particular reason.

Treatment and therapy

In the case of asymptomatic low blood return below 20 percent of the blood pumped out, no treatment is necessary, but regular monitoring is required so that timely measures can be initiated if necessary. If there is evidence of incipient dilatation of the left ventricle and thickening of the wall muscles, surgical repair or replacement of the aortic valve becomes necessary. A number of options are available for this. Open-heart surgery can be performed or, in certain cases, even minimally invasive surgery via catheter. Basically, depending on the initial situation, the options are to surgically modify the leaking heart valve so that it can perform its function again or that it is replaced by an artificial heart valve made of plastic or biological tissue.

Outlook and prognosis

With current medical options, aortic valve regurgitation can be considered good. Some patients require no further therapy at all throughout their lives because aortic valve regurgitation allows them to live adequately. They experience restrictions or prohibitions, yet the warnings are often outside the comfort zone and thus do not lead to any real impairment. In addition to regular check-ups, sufferers may perceive themselves as very healthy and have adapted their lifestyle to the conditions.Patients who require medical care also have good prospects of recovery. In a surgical procedure, a correction of the heart valve is performed so that the heart activity is subsequently fully functional again. Nowadays, the procedure is very routine and is completed within a few hours. After a few days, the patient is usually discharged from the hospital. After an appropriate rest period, he or she can return to normal life and cope with everyday life independently. Nevertheless, despite the positive outlook, the risks and side effects of an operation under general anesthesia must of course be taken into account. Good wound care is also elementary on the healing path. After the operation, the patient has the task of incorporating precautionary measures and health-endangering restrictions into his or her everyday life. Sporting activities must be adapted and extreme situations must be avoided in order not to trigger overexertion.

Prevention

Preventive measures that could effectively prevent aortic regurgitation are not known. Only treatment of essential hypertension can also be considered a preventive measure, because high blood pressure favors the development of insufficiency. However, if aortic valve insufficiency has been identified that does not affect the affected individual, regular monitoring of the wall thickness and volume of the left ventricle is recommended as a preventive measure so that surgical intervention can be performed in time before irreparable secondary damage develops, if necessary.

Follow-up care

The options for follow-up care are severely limited in aortic valve regurgitation. Here, in most cases, the patient is primarily dependent on treatment by a physician to prevent decreased life expectancy or sudden cardiac arrest. The earlier aortic valve insufficiency is detected, the higher the probability of a positive disease outcome. In most cases, the patient is dependent on surgical intervention in the event of aortic valve insufficiency. This is the only way to repair or replace the valve so that the heart can work again. The operation usually proceeds without complications and allows the affected person to live a symptom-free life. After the surgical procedure, the patient should rest and not engage in any strenuous or physical activities. In general, unnecessary strain on the body or other stressful situations should be avoided in order not to strain the heart unnecessarily. A healthy lifestyle can have a positive effect on the further course of the disease, whereby the affected person should pay particular attention to a healthy diet. A physician should also be consulted immediately at the first signs of aortic valve insufficiency.

What you can do yourself

A necessary adaptation of behavior in everyday life to aortic valve insufficiency depends on the severity of the insufficiency. The severity can reach levels I (mild) to IV (severe). The assignment of the insufficiency to one of the four severity levels depends on the proportional amount of blood returning to the left ventricle during the relaxation phase of the ventricles (diastole). Whereas stages III and IV usually require reconstructive surgery or valve replacement to improve survival and lifestyle, significant improvements in well-being can be achieved in the milder forms through behavioral adaptations and self-help measures. It is not known whether this can also influence the course of the disease. It goes almost without saying that the self-help measures also include severe restriction of tobacco and alcohol consumption. The most important part, however, is exercise and active sports. The most suitable sports are those that do not demand uncontrollable peak performance. Therefore, sports such as swimming, hiking, Nordic walking and kayaking, as well as golfing in flat terrain, are well suited. Most ball sports, such as tennis, soccer and handball, are not considered as self-help measures. It is also important to eat a balanced diet to strengthen the immune system and avoid too frequent stressful situations. Relaxation techniques such as yoga, meditation and autogenic training are recommended.