Aortic Regurgitation

Understanding the heart

The heart has four chambers - two atria and two ventricles. The walls of these chambers are mainly made of special heart muscle. During each heartbeat both of the atria contract first to pump blood into the ventricles. Then both ventricles contract to pump blood out of the heart into the arteries. There are one-way valves between the atria and ventricles, and between the ventricles and the large arteries coming from the heart. The valves make sure that when the atria or ventricles contract, the blood flows in the correct direction.

What is the aortic valve and what is aortic regurgitation ?

The aortic valve lies between the left ventricle and the aorta. The aorta is the main artery that takes blood from the heart to the body. The aortic valve has three flaps or 'cusps'. Blood flows through the valve when the left ventricle contracts at the early part of the heartbeat. When the left ventricle relaxes the aortic valve closes and the mitral valve opens to allow more blood into the ventricle ready for the next heartbeat.

Aortic regurgitation is sometimes called aortic incompetence or a leaky aortic valve. In aortic regurgitation the valve does not close properly. Therefore, blood leaks back (regurgitates) into the left ventricle from the aorta.

What are the causes of aortic regurgitation?

The main causes include the following.

Rheumatic fever

Rheumatic fever is a condition that sometimes occurs during an infection with a bacterium (germ) called the streptococcus. You body makes antibodies to the bacterium to clear the infection. However, in some people the antibodies also 'attack' various parts of the body, in particular the heart valves. Inflammation of a valve may develop which can cause permanent damage and lead to thickening and scarring years later.

Congenital causes

Various heart problems present at birth may include aortic regurgitation.

Abnormal widening of the base of the aorta

If the root of the aorta becomes abnormally wide, the cusps of the valve cannot meet and the valve becomes leaky. The tissue at the base of the aorta can be affected by various conditions such as: Marfan's syndrome, ankylosing spondylitis, rheumatoid arthritis, Reiter's syndrome, relapsing polychondritis, syphilis.

Endocarditis

This is an infection of the valve. See separate leaflet called 'Infective Endocarditis'.

What are the symptoms of aortic regurgitation?

• If the leak is small you are not likely to have any symptoms.
• If the backflow of blood becomes worse the left ventricle has to work harder with each heartbeat to pump the extra blood back into the aorta. The wall of the ventricle may then enlarge and may also become thickened (hypertrophied). Symptoms include:
  • Dizziness.
  • Chest pain (angina) when you exert yourself. This occurs because of reduced blood flow to the coronary arteries.
  • Forceful heartbeats which you may feel as palpitations.
• If the backflow of blood is severe the left ventricle may not function properly and you can develop heart failure. This causes shortness of breath, tiredness, and fluid retention in various tissues of the body. See separate leaflet called 'Heart Failure'.

What are the possible complications of aortic regurgitation?

• Heart failure may become severe and life threatening.
• Endocarditis is an uncommon complication. This is an infection of the valve. (Abnormal valves are more prone to infection than normal valves.) Unless promptly treated, endocarditis can cause serious illness. See separate leaflet called 'Infective Endocarditis'.

How is aortic regurgitation diagnosed?

• A doctor may hear a heart murmur or other abnormal noises when listening with a stethoscope. Murmurs and noises are due to blood passing through abnormal valves, or to abnormal movement of valves. There are typical murmurs and noises which occur with aortic regurgitation. Sometimes this is detected on a routine examination if you have no symptoms, and the regurgitation is mild.
• An electrocardiogram (ECG) can show that the left ventricle is thickened or enlarged.
• An echocardiography (ultrasound scan of the heart) can confirm the diagnosis.

What are the treatments for aortic regurgitation?

If the backflow of blood is mild and you have no symptoms then you may not need any treatment. If you develop symptoms or complications, various medicines may be advised to ease the symptoms. Surgery may be advised if symptoms become worse.

Medication

Medication may be advised to help ease symptoms of heart failure if heart failure develops. For details see separate leaflet called 'Heart Failure'. For example:

• Diuretics (water tablets) usually help if you are breathless. They make the kidneys produce more urine. This gets rid of excess blood and fluid which may build up in the lungs or other parts of the body with heart failure.
• ACE Inhibitors are medicines which help to reduce the amount of work the heart does and ease symptoms of heart failure.

Valve replacement surgery

This may be with a mechanical or a tissue valve. Mechanical valves are made of materials which are not likely to react with your body such as titanium. Tissue valves are made from treated animal tissue such as valves from a pig. If you need surgery, a surgeon will advise on which is the best option for your situation.

Surgical treatment has greatly improved the outlook in most people with more severe regurgitation. Surgery to replace the valve has a very good success rate. The outlook is good if the valve is treated before the heart becomes badly damaged.

Antibiotics to prevent endocarditis

You will normally be advised to take a short course of antibiotics if you have certain surgical procedures such as cystoscopy or colonoscopy. During these procedures, some bacteria may be 'pushed' into the bloodstream. The 'antibiotic cover' aims to kill any bacteria which may get into the bloodstream and helps to prevent endocarditis (described above). Most doctors who do these surgical procedures are aware of the need to recommend antibiotic cover to people with heart valve disease. The British Heart Foundation (contact details below) also lists a range of procedures that require antibiotic cover.

Dental treatments: until recently, it has also been advised that people with heart valve disease should take antibiotic cover when they have dental treatment. However, a guideline published in 2006 from the British Society for Antimicrobial Chemotherapy (BSAC) says that this is not needed in most situations. Their information aimed at patients says:

"A BSAC group of experts has spent a lot of time carefully looking at whether dental treatment procedures are a possible cause of infective endocarditis (IE) [sometimes called bacterial endocarditis (BE)], which is infection of the heart valve. After a very detailed analysis of all the available evidence they have concluded that there is no evidence that dental treatment procedures increase the risk of these infections.

Therefore it is recommended that the current practice of giving patients antibiotics before dental treatment be stopped for all patients with cardiac abnormalities, except for those who have a history of healed IE, prosthetic heart valves and surgically constructed conduits.

The main reasons for this are the lack of any supporting evidence that dental treatment leads to IE and the increasing worry that administration of antibiotics may lead to other serious complications such as anaphylaxis (severe allergy) or antibiotic resistance.

The advice from the BSAC is that patients should concentrate on achieving and keeping a high standard of oral and dental health, as this does reduce the risk of endocarditis. Help for this will be provided by your Dental Professional."

However, this guideline is controversial. It has caused a lot of debate, especially from some cardiologists (heart doctors) and dentists who maintain that antibiotic cover is still needed for dental procedures. See references below for details of some articles that deal with this controversy. Your own doctor or dentist will advise for your own particular circumstance.

Further sources of help and information

British Heart Foundation

14 Fitzhardinge Street, London, W1H 6DH
Tel - Heart Information Line: 08450 70 80 70
Web: www.bhf.org.uk