AKT · Cardiovascular/Valves & endocardium

Aortic regurgitation

Incompetent aortic valve / aortic root dilatation → diastolic backflow into the LV

Overview

Diastolic leakage of blood back into the left ventricle from an incompetent aortic valve or dilated aortic root. Chronic AR causes volume overload and a hyperdynamic, wide-pulse-pressure circulation with an early diastolic murmur; acute AR (endocarditis, dissection) is a sudden, poorly tolerated emergency. Causes include bicuspid valve, rheumatic disease, endocarditis, and root dilatation (Marfan, dissection, syphilis).

Recognise

Early diastolic murmur at the left sternal edge (heard best sitting forward, in expiration); wide pulse pressure
Collapsing (water-hammer) pulse and the eponymous signs — Corrigan's, de Musset's (head-bobbing), Quincke's (nail-bed pulsation), displaced hyperdynamic apex
Acute AR (dissection/endocarditis): sudden pulmonary oedema and cardiogenic shock with a soft/absent murmur

Red flags

Acute severe AR (aortic dissection or endocarditis) → emergency surgery — poorly tolerated, do not delay
New AR + fever → infective endocarditis; AR + tearing chest pain → aortic dissection

Differentials & how to tell them apart

Pulmonary regurgitation (Graham Steell)early diastolic murmur with pulmonary hypertension; right-sided

Mitral stenosismid-diastolic rumble with opening snap at the apex

Patent ductus arteriosuscontinuous machinery murmur

Investigations

Echo (regurgitant jet, valve and aortic root, LV size/function — the key test); ECG (LVH); CXR; CT/MRI of the aorta for root pathology; blood cultures if endocarditis suspected.

Management

Vasodilators for chronic symptomatic AR; valve replacement for symptoms/LV decline; acute AR → emergency surgery

1Confirm and quantify on echo; assess LV size/function and the aortic root. Chronic asymptomatic AR is monitored, with vasodilators for symptoms/hypertension.Gate: Acute severe AR (dissection or endocarditis) → emergency surgery — it is poorly tolerated. Don't manage it as chronic disease.
2Symptoms, or progressive LV dilatation/dysfunction → aortic valve replacement/repair (and root surgery for aortopathy).

Vasodilators (ACE inhibitor/ARB, dihydropyridine CCB) — for symptomatic chronic AR or to manage hypertension while awaiting surgery

Aortic valve replacement/repair — for symptoms or progressive LV dilatation/dysfunction; root surgery if aortopathy

Treat the cause — endocarditis (antibiotics ± surgery), dissection (emergency), Marfan root disease

Key points

Early diastolic murmur + wide pulse pressure + collapsing pulse + head-bobbing = chronic aortic regurgitation → vasodilators, surgery when symptomatic or the LV dilates. Sudden AR with shock/pulmonary oedema = acute AR from dissection or endocarditis → emergency surgery.

Monitor & prognosis

Serial echo (LV dimensions/EF) in asymptomatic patients; prompt surgery on threshold breach.

Chronic AR tolerated for years; acute AR is an emergency with high mortality if not operated.

Source: NICE NG208; ESC valve guideline