Aortic Valve Regurgitation

Overview

What is aortic valve regurgitation?

Aortic valve regurgitation develops when the aortic valve does not function correctly. To understand this condition, it's helpful to know how the aortic valve normally functions. The aortic valve works like a one-way gate, opening so that blood from the left ventricle (the heart's main pump) can be pushed into the aorta, the large artery leaving the heart. From the aorta, oxygen-rich blood flows into the branching arteries and through the body to feed the cells. When the heart rests between beats, the aortic valve closes to keep blood from flowing backward into the heart. See a picture of how the aortic valve works .

In aortic valve regurgitation, the aortic valve does not close properly. With each heartbeat, some of the blood pumped into the aorta leaks back (regurgitates) through the faulty valve into the left ventricle. The body doesn't receive enough blood, so the heart must work harder to make up for it (compensation). See a picture of aortic valve regurgitation .

Typically, symptoms do not develop for decades because the heart compensates by getting bigger so that it can pump out more blood. But, if it is not corrected, regurgitation usually gets worse over time, and symptoms such as shortness of breath and fatigue develop. At this point, an aortic valve replacement is typically needed to prevent abnormal heartbeats (arrhythmias), heart failure, and irreversible damage to the heart muscle.

In rare cases, aortic valve regurgitation comes on suddenly and requires immediate medical attention.

Some people have very small amounts of blood that leak back into the left ventricle. This usually doesn't cause any symptoms or problems. This topic focuses on the more serious cases of aortic valve regurgitation where large amounts of blood flow back across the aortic valve into the left ventricle.

What causes aortic valve regurgitation?

Any condition that damages the aortic valve can cause aortic valve regurgitation. Common causes include being born with a defective aortic valve, wear and tear from aging, infection of the lining of the heart (endocarditis), and rheumatic fever. Enlargement of the aorta, associated with high blood pressure and hardening of the arteries (atherosclerosis), can also cause aortic valve regurgitation. On rare occasions, radiation treatments to the chest can damage the aortic valve.

Rarer conditions that cause aortic valve regurgitation include a disorder of the body's connective tissues (Marfan's syndrome), a type of arthritis (ankylosing spondylitis), some autoimmune diseases, and syphilis.

The most common causes of sudden (acute) aortic valve regurgitation include:

• Endocarditis, which is an infection in the heart caused by bacteria.
• Aortic dissection, which is the separation of the inner layer of the aorta from the middle layer.
• Problems with the replacement (prosthetic) aortic valve.

Other conditions that cause acute regurgitation include trauma to the heart valve or aorta.

What are the symptoms?

In the early stages, people with chronic aortic valve regurgitation often do not have any symptoms. However, to make up for the reduced blood flow, the heart has to pump harder, and over a period of years, the left ventricle may slowly enlarge. As the heart compensates for the regurgitation, it eventually weakens, and symptoms develop. These symptoms include:

• Fatigue or weakness.
• Shortness of breath, especially with increased activity.
• Abnormal heart rhythms (arrhythmias).
• Palpitations, an uncomfortable awareness of the heart beating rapidly or irregularly.
• Angina, chest pain often brought on by exertion.
• Fainting (syncope).

In acute aortic valve regurgitation, the above symptoms develop suddenly and are often more intense. People with acute aortic valve regurgitation also may have a fast heartbeat (tachycardia). Acute aortic valve regurgitation is life-threatening and requires immediate medical attention.

How is aortic valve regurgitation diagnosed?

Your doctor may suspect that you have aortic valve regurgitation after hearing a characteristic heart murmur through a stethoscope . He or she will ask you whether you've had any symptoms and about your health in general and any family history of heart disease.

If your physical examination indicates aortic valve regurgitation, an electrocardiogram (EKG or ECG) is usually done. An echocardiogram (echo) is then done to confirm whether you have aortic valve regurgitation and, if you do, how much the valve is leaking.

How is it treated?

Treatment for aortic valve regurgitation depends on its cause and your symptoms.

Most commonly, when people are first diagnosed with chronic aortic valve regurgitation, treatment is not needed. But it is important to see your doctor regularly to monitor your condition. In some cases, one of several medicines-the calcium channel blocker nifedipine (such as Procardia), an angiotensin-converting enzyme (ACE) inhibitor, or the vasodilator hydralazine-is used to lower blood pressure and delay the progression of the disease.

In long-standing (chronic) aortic valve regurgitation, once symptoms appear-even if they are mild-or your left ventricle loses pumping power, valve replacement surgery is usually recommended to prevent or reverse heart damage.

In sharp contrast, sudden (acute) aortic valve regurgitation requires immediate surgery to prevent death.

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Frequently Asked Questions

Cause

Different factors cause sudden (acute) and long-standing (chronic) aortic valve regurgitation to develop.

Chronic aortic valve regurgitation

Causes of chronic aortic valve regurgitation include:

• Congenital heart defects. Some people are born with aortic valves that have only one (unicuspid valve) or two (bicuspid valve ) leaflets, instead of the normal valve with three leaflets (tricuspid valve). The structure of these abnormal valves often prevents them from closing completely when the heart is at rest, allowing blood to leak back into the left ventricle. These types of valves are also more susceptible to deposits forming on the surface, which can further impair the valve's ability to close properly.
• Aging. The aortic valve deteriorates with the normal wear and tear on the valve that comes with age.
• Rheumatic fever. Rheumatic fever used to be the most common cause of valvular problems in the United States, but the widespread use of antibiotics has nearly eliminated it in recent years. Rheumatic fever can develop from an untreated strep throat infection. Although individuals generally have rheumatic fever as children, the effects often are not evident until adulthood. It can lead to chronic scarring of the leaflets of the valves and prevent them from closing completely, causing regurgitation.
• Infection in the heart (infective endocarditis). Endocarditis is a common cause of aortic valve regurgitation. When bacteria begin growing on the valve or inside the heart, they form a colony, known as a vegetation, which may grow to be several centimeters in size. These colonies can prevent the valve from closing completely, causing regurgitation. The bacteria also can eat through the valve leaflet, leaving a hole through which blood can leak backward.
• Enlarged aorta (dilation of the aortic root). The portion of the aorta that is connected to the heart is called the aortic root. If it becomes enlarged (aortic root dilation), it can lead to regurgitation by pulling the leaflets of the valve apart and out of shape, causing them to leak. Aortic root dilation can be caused by age, high blood pressure, a disorder of the body's connective tissues (Marfan's syndrome), syphilis, and autoimmune diseases, in which your immune system begins to attack your own body's cells.
• The diet medicine fen-phen. Fen-phen was a popular diet drug that was taken off the U.S. market in 1997 because of its link to heart valve disease, including aortic valve regurgitation.
• Radiation treatments for cancer. On rare occasions, radiation treatments to the chest, especially in young people, can damage the aortic valve.

Acute aortic valve regurgitation

Acute regurgitation can be caused by:

• Endocarditis, an infection in the heart. Endocarditis is the most common cause of acute regurgitation.
• Problems with the replacement (prosthetic) aortic valve. Some people who have had surgery to replace the aortic valve develop aortic valve regurgitation with the new valve.
• Aortic dissection. In aortic dissection, blood can leak into a tear in the inner lining of the aorta, causing the walls of the aorta to separate. When a separation occurs, blood can seep into the middle layer of the aorta and damage the vessel and the structure of the aortic valve.
• Trauma to the chest. An injury, such as hitting the dashboard with your chest in a car accident, can damage the valve.

Acute aortic valve regurgitation is an emergency that must be treated immediately with surgery.

Symptoms

Many young people with aortic valve regurgitation do not have symptoms. When symptoms finally appear, they often indicate that the heart is significantly affected. Whether these symptoms come on gradually (as in chronic regurgitation) or more suddenly (as in acute regurgitation), they may be confused with symptoms of heart failure. See an illustration of aortic valve regurgitation .

If only a small amount of blood is leaking back through the aortic valve, you may not have symptoms, and heart function may not be affected. As the amount of leakage increases, symptoms usually appear, and the function of the heart may be affected. Symptoms found in more severe aortic valve regurgitation include:

• Shortness of breath, especially with activity.
• Fatigue and weakness.
• Fainting (syncope).
• Trouble breathing at night.
• Swelling in the legs and sometimes the rest of the body (edema).
• Awareness of the heartbeat (palpitations), especially when lying on the left side.
• Pulsations in the neck.
• Dizziness and lightheadedness.
• Abnormal heartbeats (arrhythmias).
• Chest pain (angina), often brought on by exertion (sometimes a sign of severe aortic valve regurgitation).

If acute aortic valve regurgitation develops (for example, from an infection in the heart [endocarditis]), the only symptoms may be severe shortness of breath, a rapid heart rate, and lightheadedness.

What Increases Your Risk

The risk factors for aortic valve regurgitation are:

• Congenital heart defects, such as being born with an aortic valve with one (unicuspid) or two (bicuspid) flaps, called leaflets, rather than three.
• Old age.
• Male gender.

Tell your doctor if one of your close family members has a congenital aortic valve defect, because you may be at risk for having one.

As you age, your valves sustain greater wear and are more likely to leak, increasing the risk of aortic regurgitation. Also, men are more likely than women to develop the condition.

Age; a disorder of the connective tissues (Marfan's syndrome); high blood pressure; autoimmune diseases, in which your immune system begins to attack your body's own cells; and syphilis put you at increased risk for developing an enlarged aorta, which in turn increases your risk for regurgitation.

When to Call a Doctor

Call your health professional if you have symptoms of aortic valve regurgitation such as fainting, chest pain, or shortness of breath. For more information, see the Symptoms section of this topic. Your doctor will confirm whether you have valve problems or some other condition.

Acute aortic valve regurgitation comes on suddenly, with severe shortness of breath, a rapid heart rate, and lightheadedness. Acute aortic valve regurgitation is a medical emergency: Call 911 immediately.

Who to See

Health professionals who can diagnose aortic valve regurgitation include:

• Family medicine doctors.
• General practitioners.
• Internists.
• Emergency medicine specialists.

Once you have been diagnosed, you may be referred to a cardiologist, who specializes in heart diseases. The specialist will monitor your condition and help determine when valve replacement is needed.

Exams and Tests

You should have a physical exam periodically, with the frequency depending on your age, overall health, and risk factors for various conditions. Most heart valve problems are discovered by a doctor while listening to the heart with a stethoscope. If your doctor finds aortic valve regurgitation during a routine physical, the condition will likely not have progressed to the point of being severe and needing immediate treatment. By treating the condition early, you may be able to extend, possibly even by several years, the time before you need valve replacement surgery. Because all artificial valves eventually wear out, this could mean one fewer valve replacement in your lifetime.

In testing for aortic valve regurgitation, your doctor will try to determine whether you have the condition and what type of regurgitation you have (acute or chronic). The doctor also will want to assess how severe the regurgitation is and whether you have any complications, such as abnormal heartbeats (arrhythmias) or heart failure.

A medical history and physical exam are a routine part of any evaluation of how well your heart is working. Aortic valve regurgitation can generally be diagnosed by physical exam.

Further testing may be needed to determine how much the valve is leaking. Tests also are needed if you have symptoms, because they can easily be confused with symptoms of several other heart conditions, including coronary artery disease (CAD) and heart failure. Aortic valve regurgitation also can be confused with other heart valve conditions.

During the physical exam, your doctor will listen for an extra heart sound (a murmur). If you have a certain type of heart murmur, your doctor may suspect aortic valve regurgitation and suggest further tests, which may include:

• Echocardiogram (echo)/transesophageal echocardiogram (TEE). Echocardiography (echo) can be used to look at the heart valves and the shape of the leaflets and to see whether the valves are leaking. Echocardiograms also measure the ability of the lower left heart chamber (left ventricle) to fill with blood and pump properly. Echo also helps measure heart size and may show whether the heart muscle is abnormally thickened because of aortic valve regurgitation. Health professionals use an echo to guide treatment decisions, such as whether to perform valve surgery, which may be needed if there is evidence of an enlarged left ventricle (a sign of heart failure).
• Electrocardiogram (ECG, EKG). The results of electrocardiography (electrocardiogram) may show abnormal electrical activity, suggesting that your heart is enlarged or has an increased workload caused by the backflow of blood or by an arrhythmia.
• Chest X-ray. If you have aortic valve regurgitation, a chest X-ray may show that the lower left ventricle is enlarged. In some cases, the blood vessel leaving the heart (aorta) may be enlarged just beyond the aortic valve.
• Exercise electrocardiogram. Exercise electrocardiography may be needed to see how the heart responds to exercise in a person who does not exercise regularly or when symptoms are present.
• Angiogram/aortogram. During an angiogram of the aorta (aortogram), a thin, flexible tube called a catheter is placed into the femoral artery in the upper thigh and threaded to the left ventricle and aorta. Dye is then injected through the catheter, and the flow of the dye through the aortic valve can help determine how much the aortic valve is leaking. Also, coronary angiogram, in which the coronary arteries are viewed, is usually done at the same time.
• Radionuclide ventriculogram (nuclear scanning). Ventriculography can measure how well the left ventricle is pumping and how much blood is pumped out of the chamber with each heartbeat.

If you have aortic valve regurgitation, you will see your doctor for regular exams including an echocardiogram. How often you have an echocardiogram depends on the severity of your regurgitation. Mild regurgitation requires an echocardiogram every 2 to 3 years, a moderate condition requires an echo every year, and with severe regurgitation you may have to have an echo every 4 to 6 months.

Treatment Overview

Treatment for aortic valve regurgitation usually depends on whether you have symptoms from your leaky heart valve and whether your heart is pumping effectively. Other factors that play a part in treatment decisions include your age (older people may be at greater-than-average risk for complications of some treatments), risks associated with surgery, and the experience of the doctor and health care facility performing the procedures.

If you have symptoms, surgical treatment may be needed. If your symptoms develop suddenly (acute aortic regurgitation), immediate surgery to replace the valve is usually needed.

Since the treatment for acute aortic regurgitation is usually limited to immediate surgery, this treatment overview will discuss the treatment of chronic aortic valve regurgitation.

Initial treatment

Your doctor will assess the cause and severity of your aortic valve regurgitation and how effectively your heart is able to compensate for it. In addition to some preliminary tests-including routine blood tests and an electrocardiogram-an exercise electrocardiogram (also called exercise EKG or cardiac stress test) can be done to see whether you have any symptoms while you are exercising. After these tests, an echocardiogram will probably be done to estimate your ejection fraction, which is a measure of the left ventricle's ability to fill with blood and pump properly. This measurement will help your doctor determine when surgery is needed.

If your regurgitation is mild and you do not have any symptoms, your doctor may not prescribe daily heart medicines. If you have had rheumatic fever, you may need to take antibiotics daily for the following 5 to 10 years, depending on your heart's condition.

If your regurgitation is moderate to severe, your doctor may prescribe the calcium channel blocker nifedipine (such as Procardia), an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB), or the vasodilator hydralazine. These medicines, which are typically prescribed for high blood pressure, have been shown to slow the progression of aortic valve regurgitation and delay the need for valve replacement surgery.

Since your heart is already working overtime to keep up with your body's needs, your doctor will probably recommend specific lifestyle changes to decrease your heart's workload.

• If you smoke, your doctor will strongly advise that you quit and avoid secondhand smoke too. Your doctor may prescribe medicine and therapy to help you quit smoking. Studies show that the combination of nicotine replacement therapy, use of the medicine bupropion (Zyban or Wellbutrin), and supportive therapy significantly increases long-term success in quitting.¹ For more information, see the topic Quitting Smoking.
• Your doctor will also recommend that you follow a heart-healthy diet and get regular exercise. If you do not have symptoms of aortic valve regurgitation, your doctor may recommend regular, light aerobic exercise, such as walking. But do not start an exercise program on your own without first discussing it with your doctor. If you can exercise, do activities that raise your heart rate. Try to do at least 2½ hours a week of moderate exercise. One way to do this is to be active 30 minutes a day, at least 5 days a week. It's fine to be active in blocks of 10 minutes or more throughout your day and week.²
• Good dental hygiene and regular dental checkups are important, because poor dental health can increase the risk of bacteria spreading to your heart.
• Avoid getting sick from the flu. Get a flu shot every year.

Report any symptoms of chest pain, fainting, and shortness of breath to your doctor immediately. You will also need to follow up after 2 or 3 months for another screening and have regular appointments to determine whether your condition is getting worse.³

Ongoing treatment

Symptoms of chronic aortic valve regurgitation most commonly develop when you are in your 40s or 50s, but there is no way to gauge how quickly symptoms will develop in each case. Some people remain free of symptoms for decades, while in others, progression to symptoms takes 2 to 3 years.

Regardless, you will need to have regular echocardiograms (echos) to determine whether your aortic regurgitation is getting worse. The echocardiogram estimates your ejection fraction-the amount of blood that is leaving your left ventricle, the heart's main pump-and the size of your left ventricle. A declining ejection fraction and an increasing diameter of your left ventricle indicate decreasing heart function and worsening regurgitation.

Mild regurgitation requires an evaluation with an echocardiogram every 2 to 3 years, a moderate condition requires an echo every year, and with severe regurgitation you may have to have an echo every 4 to 6 months.

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend having aortic valve replacement surgery if you have severe regurgitation and one of the following conditions:³

• You have symptoms.
• Your ejection fraction drops below 50% at rest.
• Your left ventricle enlarges to more than 55 millimeters at rest.
• You are going to have another open-heart surgery such as coronary artery bypass graft surgery.

Your doctor may recommend that you have surgery even if you do not have symptoms because symptoms typically only occur after the condition has progressed to the point that it has already damaged the heart.

It is extremely important that you report any symptoms or changes in your symptoms to your doctor. Your doctor will rely on you to provide an accurate assessment of how you feel and how your symptoms have changed since your last visit.

If you are not already taking medicines, at some point your doctor may prescribe the calcium channel blocker nifedipine (such as Procardia), an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB), or the vasodilator hydralazine. These medicines, which are usually prescribed for high blood pressure, have been shown to slow the progression of aortic valve regurgitation and delay the need for valve replacement surgery.

If aortic valve regurgitation causes chest pain, medicines called nitrates (nitroglycerin) can sometimes be tried to help relieve the pain. Antiarrhythmic medicines may be needed if aortic valve regurgitation leads to abnormal heart rhythms (arrhythmias). If aortic valve regurgitation causes heart failure, medicines such as digoxin and diuretics are often used to help the heart pump more effectively.

People who have had rheumatic fever may need to take antibiotics daily for 5 to 10 years after the infection, depending on the damage to the heart.

Avoid getting sick from the flu. Get a flu shot every year.

Your doctor will stress that you quit smoking and avoid secondhand smoke, eat a heart-healthy diet, limit your sodium intake, and possibly follow an exercise program. If you can exercise, do activities that raise your heart rate. Prescribed exercise is often part of a cardiac rehabilitation program.

Treatment if the condition gets worse

If your aortic valve regurgitation is getting worse and your heart is not able to compensate for the extra workload, your doctor will recommend that you have aortic valve replacement surgery, even if you do not have symptoms. But if you have symptoms, aortic valve replacement surgery is the only cure for aortic regurgitation.

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend having aortic valve replacement surgery if you have severe regurgitation and one of the following conditions:³

• You have symptoms.
• Your ejection fraction drops below 50% at rest.
• Your left ventricle enlarges to more than 55 millimeters at rest.
• You are going to have another open-heart surgery such as coronary artery bypass graft surgery.

Your doctor may recommend that you have surgery even if you do not have symptoms because symptoms typically only occur after the condition has progressed to the point that it has already damaged the heart.

Other risk factors, including age, speed of deterioration, and overall health, will also be considered in deciding the timing of surgery.

A small number of people may suffer from other severe and debilitating conditions that make valve replacement surgery too dangerous. Additionally, some people may choose not to have valve replacement surgery for personal or philosophical reasons. For example, a person may believe that he or she does not have enough remaining years to make surgery worthwhile.

People with symptomatic aortic valve regurgitation who do not have corrective surgery face progression to the severe stages of heart failure and, on average, have a life expectancy of 2 to 4 years. This means they will probably have to cope with an end stage to the disease. As you near the end stage of your condition, you may want to consider making advance directives, which are documents that allow you to determine the type of care you wish to receive in case you are not able to make your wishes known at the end of your life. For more information, see the topic Care at the End of Life.

Ongoing Concerns

After you are diagnosed with long-lasting (chronic) aortic valve regurgitation, it is important that you work with your doctor to monitor the condition of your valve and report any shortness of breath, fainting, chest pain, or other symptoms immediately. (Symptoms of acute aortic valve regurgitation come on suddenly. Acute regurgitation is an emergency that requires immediate valve replacement surgery.)

If you do not have symptoms

Many people are surprised when diagnosed with chronic aortic valve regurgitation because they do not have symptoms. People with chronic regurgitation, even when moderate or severe, can have a good prognosis for many years.

Even though you may feel fine, it is important to guard against a false sense of security during this stage of chronic aortic valve regurgitation. Significant damage can occur to your heart during this period.

If you have symptoms

If you have symptoms, valve replacement surgery is the only cure for aortic valve regurgitation. If you cannot or choose not to have surgery, you likely will develop heart failure and your life span will be significantly reduced. The condition usually reduces average life expectancy to about 2 years if you develop heart failure and 4 years if you develop chest pain (angina).⁴ With corrective surgery, you may reach a normal life expectancy. For more information, see the topic Heart Failure.

Symptoms of chronic regurgitation most commonly develop in a person's 40s or 50s, but there is no way to gauge how quickly symptoms will develop in an individual case. Some people can remain symptom-free for decades, while in others, progression to symptoms takes 2 to 3 years. You may develop symptoms more quickly if the left ventricle does not contract fully (depressed systolic function).

Complications may develop from severe, symptomatic chronic aortic valve regurgitation. Heart failure, an infection in your heart (endocarditis), and irregular heartbeats (arrhythmias) are all common complications of aortic valve regurgitation that can be delayed if not prevented entirely. Reducing your risk factors for these conditions can help prevent complications. For instance, because both high blood pressure (hypertension) and regurgitation can cause heart failure, if you have both it is especially important to control your blood pressure.

It may be better to have valve replacement surgery before symptoms develop from regurgitation. Once the left ventricle becomes significantly enlarged, heart damage can be irreversible. The left ventricle can enlarge even while you are symptom-free. For this reason, visit your doctor regularly for appropriate monitoring.

Living With Aortic Regurgitation

Since having aortic valve regurgitation means your heart is working overtime to keep up with your body's needs, your doctor will probably recommend specific lifestyle changes to decrease your heart's workload.

• If you smoke, your doctor will strongly advise that you quit and avoid secondhand smoke too. Your doctor may prescribe medicine and therapy to help you quit smoking. Studies show that the combination of nicotine replacement therapy, the medicine bupropion (Zyban or Wellbutrin), and supportive therapy significantly increases long-term success in quitting.¹ For more information, see the topic Quitting Smoking.
• Your doctor will also recommend that you follow a heart-healthy diet and limit your sodium intake.
• If you do not have symptoms, your doctor may recommend regular, light aerobic exercise, such as walking. Do not start an exercise program on your own without first discussing it with your doctor. If you can exercise, do activities that raise your heart rate. Try to do at least 2½ hours a week of moderate exercise. One way to do this is to be active 30 minutes a day, at least 5 days a week. It's fine to be active in blocks of 10 minutes or more throughout your day and week.²
• If you are overweight, you may want to try to lose weight to reduce your heart's workload. The American Heart Association (AHA) publishes dietary guidelines for general heart health.
• Practice good dental hygiene and have regular checkups. Good dental health is especially important because bacteria can spread from infected teeth and gums to the heart valves.
• Avoid getting sick from the flu. Get a flu shot every year.

If you have an artificial valve, you may need to take antibiotics before you have certain dental or surgical procedures. The antibiotics help prevent an infection in your heart called endocarditis.

People who have had rheumatic fever may need to take antibiotics for 5 to 10 years following the infection, depending on the damage to the heart.

If you have severe aortic valve regurgitation, your doctor will probably recommend that you avoid strenuous physical activity.

If you have chronic aortic regurgitation, you are likely to live for many years without symptoms. During this symptom-free period, you need to monitor the function of the lower left chamber of the heart (left ventricle) with regular doctor visits and echocardiogram tests. How often you need to see your doctor depends on the severity of your condition. Follow-up visits are generally scheduled every 6 to 12 months.

Report any symptoms of chest pain, fainting, and shortness of breath to your doctor immediately. These are signs that you are likely to need surgery.

Medications

Treatment for chronic aortic valve regurgitation includes medicines to reduce blood pressure. If you have valve replacement surgery, you will need to take medicines to prevent infection and blood clots around the artificial valve.

If your regurgitation is moderate to severe, your doctor may prescribe the calcium channel blocker nifedipine (such as Procardia), an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB), or the vasodilator hydralazine. These medicines, which are typically prescribed for high blood pressure, have been shown to slow the progression of aortic valve regurgitation and delay the need for valve replacement surgery.

If aortic valve regurgitation causes chest pain, medicines called nitrates (nitroglycerin) can sometimes be tried to help relieve the pain. Antiarrhythmic medicines may be needed if the regurgitation leads to irregular heart rhythms (arrhythmias). If aortic valve regurgitation causes heart failure, medicines are often used to help the heart pump more effectively. These include digoxin and diuretics.

If your valve is replaced with an artificial heart valve made of plastic, metal, or cloth, you will have to take anticoagulant medicine, such as warfarin (Coumadin, for example), to prevent blood clots for the rest of your life.

If you take warfarin, don't suddenly change your intake of foods that are rich in vitamin K. Vitamin K can interfere with the action of anticoagulants, making it more likely that your blood will clot. For more information, see:

If you have an artificial valve, you may need to take antibiotics before you have certain dental or surgical procedures. The antibiotics help prevent an infection in your heart called endocarditis.

People who have had rheumatic fever may need to take antibiotics for 5 to 10 years after the infection, depending on the damage to the heart.

Anticoagulants: Vitamin K and your diet

Surgery

Valve replacement surgery is the only cure for sudden (acute) aortic valve regurgitation or for long-term (chronic) regurgitation when symptoms develop or signs indicate that the lower left heart chamber (left ventricle) is starting to fail.

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend having aortic valve replacement surgery if you have severe regurgitation and one of the following conditions:³

• You have symptoms.
• Your ejection fraction drops below 50% at rest.
• Your left ventricle enlarges to more than 55 millimeters at rest.
• You are going to have another open-heart surgery such as coronary artery bypass graft surgery.

Your doctor may recommend that you have surgery even if you do not have symptoms because symptoms typically only occur after the condition has progressed to the point that it has already damaged the heart.

If you choose to have aortic valve replacement surgery , you can expect to live to a normal or near-normal life expectancy. There are some risks associated with surgery, but the risk of dying during surgery overall is still reasonably low (5% or less).⁵ You may be at higher risk for complications if your left ventricle is working poorly. Surgery may not be recommended in some people who are in extremely poor health.

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Organizations

Related Information

• Aortic Valve Stenosis
• Chest Pain
• Coronary Artery Disease
• Endocarditis
• Heart Failure

References

Citations

1. Burns P, et al. (2003). Management of peripheral arterial disease in primary care. BMJ, 326(7389): 584-588.

2. U.S. Department of Health and Human Services (2008). 2008 Physical Activity Guidelines for Americans (ODPHP Publication No. U0036). Washington, DC: U.S. Government Printing Office. Available online: http://www.health.gov/paguidelines/pdf/paguide.pdf.

3. Bonow RO, et al. (2006) ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease). Circulation, 114(5): e84-e231.

4. Otto CM, Bonow RO (2008). Aortic regurgitation section of Valvular heart disease. In P Libby et al., eds., Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine, 8th ed., pp. 1635-1646. Philadelphia: Saunders Elsevier.

5. Rahimtoola SH (2004). Aortic valve disease. In V Fuster et al., eds., Hurst's The Heart, 11th ed., vol. 2, pp. 1643-1667. New York: McGraw-Hill.

Other Works Consulted

• American Heart Association and American College of Cardiology (2006). AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update. Circulation, 113(19): 2363-2372. [Erratum in Circulation, 113(22): 847.]

• Curtin RJ, Griffin BP (2006). Valvular heart disease. In DC Dale, DD Federman, eds., ACP Medicine, section 1, chap. 11. New York: WebMD.

• Hirsch J, et al. (2008). Executive summary: American College of Chest Physicians evidence-based clinical practice guidelines (8th ed.). Chest, 133(6): 71-109.

• Nishimura RA, et al. (2008) ACC/AHA 2008 guideline update on valvular heart disease: Focused update on infective endocarditis: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation, 118(8): 887-896.

• Stewart WJ, Carabello BA (2007). Aortic valve disease. In EJ Topol et al., eds., Textbook of Cardiovascular Medicine, 3rd ed., pp. 366-388. Philadelphia: Lippincott Williams and Wilkins.

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