--- title: Aortic regurgitation description: What aortic regurgitation is, why it develops, how it is detected, which treatment approaches clinical guidelines describe and when urgent help is needed. type: disease aliases: - AR - aortic insufficiency - aortic valve regurgitation sources: - tier: guideline org: esc title: 2025 ESC/EACTS Guidelines for the management of valvular heart disease year: 2025 doi: 10.1093/eurheartj/ehaf194 url: https://doi.org/10.1093/eurheartj/ehaf194 - tier: guideline org: minzdrav-rf title: Аортальная недостаточность year: 2025 url: https://cr.minzdrav.gov.ru/view-cr/983_1 - tier: guideline org: nice title: 'Heart valve disease presenting in adults: investigation and management (NG208)' year: 2021 url: https://www.nice.org.uk/guidance/ng208 - tier: reference org: msd-manuals title: Aortic Regurgitation year: 2025 url: https://www.msdmanuals.com/professional/cardiovascular-disorders/valvular-disorders/aortic-regurgitation - tier: reference org: msd-manuals title: Cardiac Auscultation year: 2025 url: https://www.msdmanuals.com/professional/cardiovascular-disorders/approach-to-the-cardiac-patient/cardiac-auscultation sources_checked: 2026-10-12 review: null --- Aortic regurgitation (aortic insufficiency) is a heart valve disease in which the leaflets of the aortic valve do not close properly or are destroyed. As a result, during diastole — when the left ventricle relaxes and fills — some blood flows back from the aorta into the left ventricle. It can be chronic or acute; acute regurgitation is very uncommon.

The diagram shows diastole: the left ventricle is relaxed and fills with blood from the left atrium. Normally the aortic valve leaflets are closed at this time, so blood does not flow back from the aorta into the ventricle.

In aortic regurgitation the valve leaflets do not close in diastole, and some of the blood pumped into the aorta flows back into the left ventricle. The ventricle receives blood from two sides at once: from the left atrium and as backflow from the aorta.

## Why it happens The causes fall into two groups. In the first, the valve leaflets themselves are damaged: they are stretched and thinned, destroyed by infection, or stiffened by atherosclerosis or rheumatic disease. In the second, the ascending aorta is diseased (an aneurysm, dissection or rupture), and because of this the valve no longer closes properly. A fairly common cause is a valve that has been abnormal from birth, for example a valve with two leaflets instead of the usual three. When aortic regurgitation appears at a young age, this is typical of such congenital valve defects. Acute aortic regurgitation is most often caused by a dissection of the ascending aorta or by infective endocarditis — an infection of the valve. In chronic regurgitation the left ventricle gradually enlarges and thickens and copes with the extra blood for a long time. Eventually, however, the heart can no longer cope: heart rhythm problems, weakening of the left ventricle and heart failure develop. Causes of aortic regurgitation (AR) include changes in the aortic valve (AV) cusps themselves: atherosclerotic changes, infective endocarditis (IE) with cusp destruction, congenital anomalies (bicuspid (BAV), unicuspid and quadricuspid AV) and, less often, trauma. With structurally normal cusps, AR develops when the aortic root dilates, which accompanies aneurysm of the aortic root and ascending aorta; AR frequently complicates dissection of the ascending aorta. Other fairly common causes are sclerotic degeneration, rheumatic disease and connective tissue dysplasia. During diastole the LV receives both blood from the LA and blood regurgitated from the aorta, causing LV volume overload. In acute severe AR a large volume of blood returns into a normal-sized LV that has no time to adapt; this can cause a sudden catastrophic rise in LV filling pressure and a fall in cardiac output. According to the Framingham study, the prevalence of AR is 4.9% in the population, with moderate or severe regurgitation in 0.5% of those examined. ## Symptoms Chronic aortic regurgitation usually causes no symptoms for years, sometimes decades. When the heart can no longer cope, breathlessness appears — first on exertion, then also at rest. Later come attacks of severe breathlessness and heart rhythm problems. A person may feel their heart pounding in the chest and a "throbbing" in the head. Chest pain can occur even when the coronary arteries are not affected. How a person feels does not always reflect the state of the heart. In at least a quarter of people the left ventricle starts to work less well before any symptoms appear, so an examination alone is not enough and an echocardiogram is needed. Acute regurgitation looks different: severe breathlessness or a feeling of suffocation comes on suddenly. Most patients with chronic AR remain asymptomatic during the compensated phase, which can last for years or decades. Progressive exertional dyspnoea, orthopnoea, paroxysmal nocturnal dyspnoea and palpitations then develop insidiously. Angina affects relatively few patients without coexisting coronary artery disease (CAD) and, when it occurs, is especially common at night. Acute AR causes symptoms of heart failure and cardiogenic shock (hypotension with resulting multisystem organ damage). ## How it is diagnosed When listening to the heart, the doctor may hear a murmur while the heart relaxes. In acute regurgitation this murmur may be quiet or not heard at all, even if the condition is severe. In significant regurgitation the upper (systolic) blood pressure is often raised and the lower (diastolic) pressure is markedly reduced. If the doctor suspects valve disease because of the type of murmur, family history, age or past illnesses, guidelines advise considering an echocardiogram, and offering one if there is breathlessness, angina or swelling. The key test is an ultrasound scan of the heart (echocardiogram). It confirms the valve disease, shows how severe it is and helps choose when and how to treat it. An ECG and a chest X-ray are also done, and if the aorta is enlarged it is examined with CT or MRI. The murmur of AR is a blowing, high-pitched, decrescendo diastolic murmur beginning soon after the aortic component of the second heart sound (A2). It is generally louder in chronic AR and may be soft or absent in acute AR even if severe. In significant AR systolic blood pressure is often raised, diastolic pressure is markedly reduced and pulse pressure is wide. Pathognomonic external signs of severe AR are visible pulsation of the common carotid arteries (Corrigan's sign), a bounding or collapsing pulse, and head bobbing (de Musset's sign). Echocardiography is recommended to diagnose chronic AR and assess its cause in all patients with suspected AR; in BAV, an initial echocardiogram is also needed to assess the diameter of the aortic root and ascending aorta. By severity, AR is graded as mild, moderate or severe; grading by numbers (1, 2, 3, 4) is not recommended. Signs of severe chronic AR in the table of the Russian Ministry of Health guideline: vena contracta >6 mm, pressure half-time less than 200 ms, regurgitant volume >60 mL per beat, regurgitant fraction >50%, effective regurgitant orifice area >0.30 cm², and LV size usually enlarged. ECG changes are non-specific: signs of LV hypertrophy, left axis deviation and LA enlargement. The coronary arteries are assessed before surgery: approximately 20% of patients with severe AR have significant CAD, even if no angina is present. The Russian Ministry of Health guideline lists indications for coronary angiography before intervention: age over 40, symptoms or history of CAD, signs of myocardial ischaemia, LVEF below 50%, and one or more CAD risk factors (class I, level A); when the probability of CAD is low, CT coronary angiography may be considered (class IIa, level C). ## How it is treated The only way to effectively correct severe aortic regurgitation is an operation. Surgery is recommended for severe regurgitation with symptoms, even if the left ventricle is still working normally. It is also recommended without symptoms if an echocardiogram shows that the left ventricle has enlarged or is pumping less well. If a person is due to have coronary bypass surgery, or an operation on the ascending aorta or on another valve, severe regurgitation is corrected during the same operation. Usually the valve is replaced with an artificial one; less often it is repaired. In selected patients, in hospitals with extensive experience of such operations, the valve can be kept and repaired if a lasting result is expected. After replacement with a mechanical valve, lifelong treatment with medicines that reduce blood clotting is needed. Medicines are used to treat heart failure and high blood pressure. While surgery is not yet needed, the doctor monitors the person regularly with echocardiograms. If surgery is indicated, delaying it is dangerous: declining or postponing surgery worsens the results of treatment and the outlook, even if the operation is done later. Thresholds for surgery differ between guidelines. 2025 ESC: AV surgery is recommended in symptomatic patients with severe AR regardless of LV function (class I, level B), and in asymptomatic patients with LVESD >50 mm, LVESDi >25 mm/m² (especially in patients with small body size, BSA less than 1.68 m²) or resting LVEF ≤50% (class I, level B). Russian Ministry of Health guideline: in asymptomatic patients, LVESD >50 mm or LVESDi >25 mm/m² in patients of small body size, or LVEF below 50% (class I, level B). NICE suggests considering referral for intervention in asymptomatic severe AR if LVEF is less than 55%, end-systolic diameter is more than 50 mm or end-systolic diameter index is more than 24 mm/m². Positions on transcatheter aortic valve implantation (TAVI) differ. The 2025 ESC guideline states that TAVI may be considered for severe AR in symptomatic patients ineligible for surgery according to the Heart Team, if the anatomy is suitable (class IIb, level B). The Russian Ministry of Health guideline does not recommend TAVI for patients with isolated AR (class III, level B); in some patients in whom surgery with cardiopulmonary bypass is contraindicated, a centre with extensive TAVI experience may consider it as a life-saving intervention if the annulus size is suitable and there is at least minimal calcification. TAVI is challenging in AR because of the dilated aortic annulus and lack of sufficient leaflet calcification, leading to prosthetic valve migration and/or paravalvular leak. Drug therapy for chronic heart failure is recommended for all patients with severe AR (class I, level A); patients with clinical manifestations of the valve disease need surgery rather than drug therapy. In asymptomatic patients with severe AR, follow-up echocardiography is performed every 6–12 months (class I, level A). ## When to call an ambulance Acute severe aortic regurgitation is dangerous: the risk of pulmonary oedema and cardiogenic shock is high, and the myocardial ischaemia it causes can lead to sudden death. If acute regurgitation is suspected because of aortic dissection or endocarditis, emergency admission to a hospital with a cardiac surgery service is needed. If severe breathlessness, a feeling of suffocation or chest pain comes on suddenly, call your local emergency number (112 in the EU, 911 in the US and Canada, 999 in the UK). Acute regurgitation can also cause weakness, cold hands and feet, a fast pulse and low blood pressure — these are also a reason to call for emergency help. If a person with known aortic regurgitation, including after valve surgery, develops or has a sharp worsening of tiredness, breathlessness, swelling or irregular heartbeats, or has lost consciousness, they need an unscheduled cardiology appointment as soon as possible. If severe breathlessness, a feeling of suffocation or chest pain comes on suddenly, do not wait for an appointment — call your local emergency number (112 in the EU, 911 in the US and Canada, 999 in the UK).