SUMMARY: 

Aortic regurgitation (AR) is a condition where the aortic valve does not close properly, either due to primary disease of aortic valve leaflets and/or dilatation of aortic root and ascending aorta.  

• Causes of AR 
• Signs and Symptoms of AR 
• Diagnosis and Follow-Up 
• Stages of Aortic Regurgitation 
• Medical Therapy of AR 
• Intervention of Acute AR 
• Intervention of Chronic AR 
• Antiplatelet/Anticoagulant Therapy Post AVR 

Causes of AR 

• Primary leaflet abnormalities 
  • Rheumatic disease | Congenital (i.e., bicuspid) | Infective Endocarditis | Myxomatous valve disease | Trauma 
• Aortic root abnormalities: 
  • Chronic hypertension | Marfan syndrome, | Aortic Dissection | Ehlers-Danlos syndrome | Syphilitic aortitis | Systemic inflammatory disorders 

Signs and Symptoms of AS: 

• Symptoms: Exertional dyspnea | orthopnea| Paroxysmal nocturnal dyspnea |Angina late in course 
• Signs:  
  • Wide pulse pressure 
  • Apical impulse is hyperdynamic and displaced laterally and inferiorly 
  • Harsh systolic flow murmur (from increased total stroke volume) and high frequency diastolic murmur 
  • 3^rd heart sound (S3) may be heard 

Diagnosis and Follow-Up: 

• A transthoracic and/or transesophageal echocardiogram to confirm presence, severity and possibly etiology of AR.  
• Severe AR is defined by echocardiography as short deceleration time on aortic flow velocity curve (<300 msec) 
• In the chronic setting, severe AR is associated with dilation of left ventricular size 

• Frequency of TTE in asymptomatic patients with AR: 

Severity	Frequency
Mild	Every 3-5 years
Moderate	1-2 years
Severe (asymptomatic)	Every 6 months to 1 year. (If LV is dilated more frequently)

Stages of Aortic Regurgitation: 

• Stage A: At risk of AR. Patients with bicuspid aortic valve | history of rheumatic fever or known rheumatic heart disease |diseases of the aortic sinuses or ascending aorta. 
• Stage B: Progressive AR: mild to moderate AR 
• Stage C: Asymptomatic Severe AR 
• Stage D: Symptomatic Severe AR 

Medical Therapy of AR: 

• Stage B-C patients:  Hypertension (SBP > 140 mmHg) should be treated accordingly. In the absence of systemic hypertension, vasodilating drug are not indicated 
• Stage D patients and/or LV systolic dysfunction but prohibitive surgical risk, heart failure guideline directed medical therapy is recommended.  

Intervention of Acute AR: 

• Acute severe AR from infective endocarditis or aortic dissection, medical therapy to reduce LV afterload can be employed as a TEMPORIZING measure, but surgery should not be delayed especially if hypotension, pulmonary edema, or evidence of hypoperfusion. 

Intervention of Chronic AR: 

• Aortic Valve Replacement (AVR) is indicated in patients with SYMPTOMATIC severe AR 
• AVR is indicated in ASYMPTOMATIC patients with severe AR and LVEF ≤ 55% 
• AVR is indicated in ASYMPTOMATIC patients with severe AR if undergoing cardiac surgery for other indications 
• AVR can be considered in ASYMPTOMATIC patients with severe AR and normal LVEF >55% if LV is severely enlarged (LV end systolic diameter >50 mm or LV end systolic diameter > 25 mm/m²) 

Antiplatelet/Anticoagulant Therapy Post AVR: 

• Patients with a bioprosthetic AVR , daily low-dose aspirin is recommended lifelong in addition to VKA anticoagulation with INR goal of 2.5 for first 3-6 months 
• Patients with a mechanical AVR, anticoagulation ONLY with vitamin K antagonist (VKA) is recommended. *DOACs (Direct Oral Anticoagulants) are contraindicated* 
• INR goals for patients with mechanical valves: 

Mechanical AVR	INR goal
Mechanical AVR with On-X valve	1.5-2
Mechanical AVR with no other risk factors*	2.5
Mechanical AVR with other risk factors*	3

*Risk factors: older generation valve | atrial fibrillation | previous thromboembolism | hypercoagulable state |LV dysfunction 

Learn More – Primary Sources: 

2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease 

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