What Causes Aortic Incompetence?

Aortic regurgitation can be caused by either primary disease of the aortic valve leaflets or aortic root dilation:

• Valve leaflets
  • Rheumatic heart disease
  • Congenital and degenerative
  • Endocarditis
• Aortic root
  • Connective tissue disorders (Marfan's syndrome, Ehlers-Danlos syndrome)
• Aortitis (inflammatory condition of the aortic root)
  • Aortic dissection
• Other causes
  • Widening of the aorta for unknown reasons
  • Calcium buildup
  • Certain types of arthritis (ankylosing spondylitis, rheumatoid arthritis, and reactive arthritis)
  • Certain autoimmune diseases, such as lupus
  • Syphilis, a sexually transmitted infection
  • Use of certain appetite-suppressing medicines
  • Bacterial infection of the heart valve (endocarditis)
  • Tearing of the aorta
  • Injury

Long-term aortic valve regurgitation is caused by birth defects in the heart, calcium accumulation on the valve, and an enlarged aorta. Endocarditis and damage to the heart are two causes of sudden aortic valve regurgitation.

Aortic valve regurgitation occurs more often with old age and is most common in men in the age group of 30-60 years. However, it can affect anyone.

Although the specific etiology of the disease is unknown, risk factors include the following:

• Nonmodifiable risk factors
  • Older age
  • Gender
  • Family history
  • Genetics
• Modifiable risk factors
  • Uncontrolled high blood pressure
  • Trauma or injury
  • Appetite-suppressing medicines
• Existing conditions
  • Congenital heart disease
  • Rheumatic fever
  • Endocarditis
  • Aortic dissection
  • Trauma to the heart valve or aorta

Acute

Acute aortic incompetence is a life-threatening condition that occurs when there is a sudden increase in left atrial pressure that causes pulmonary edema and cardiogenic shock. Valvular incompetence develops quickly, leaving no opportunity for compensatory changes. Blood regurgitation during diastole raises the left ventricular end-diastolic volume (and pressure). The effects of this can happen in two ways.

• Reduced coronary flow: Regurgitant flow decreases, leading to myocardial ischemia or angina depending on the severity.
• Increased end-diastolic pressure: Causes pulmonary edema and dyspnea by elevating pulmonary pressures. Cardiogenic shock can occur in serious cases.

Chronic

People with chronic aortic regurgitation may be asymptomatic for decades. Valvular incompetence takes time to develop.

Blood regurgitation during diastole raises the left ventricular end-diastolic volume. This causes systolic and diastolic dysfunction, as well as left ventricular dilatation, which allows for a larger stroke volume to compensate for regurgitant flow supported by ventricular hypertrophy. A further increase in preload cannot be met by increased contractility, and heart failure develops.

Aortic incompetence often has no symptoms for many years. Symptoms can appear gradually or suddenly and may include:

• Uneven, rapid, racing, pounding, or fluttering pulse
• Heart murmur
• Palpitations (sensation of the heart beating)
• Hard pulses in the arms and legs
• Shortness of breath with activity or when lying down
• Chest pain, angina type (rare)
• Fainting
• Fatigue
• Swelling in the feet, legs, or abdomen
• Low diastolic blood pressure
• Signs of fluid in the lungs

Treatment for aortic regurgitation varies depending on your symptoms and how severely they affect the function of your valve. If you have no symptoms or only mild symptoms, you may only need an echocardiogram and to be monitored by a healthcare provider.

Aortic incompetence treatment options may include:

• Medications
  • Digitalis compounds to improve blood flow
  • Diuretics to reduce water retention
  • Vasodilators to widen the blood vessels
  • Antibiotics to prevent an infection of a damaged heart
• Surgery
  • Done to repair or replace the aortic valve
  • The decision is based on your symptoms, as well as the condition and function of your heart
• Mechanical valve
  • Requires long-term anticoagulation
  • Long life expectancy, which reduces the need for a second operation
  • Suitable for younger people
• Bioprosthetic valve
  • No need for long-term anticoagulation
  • Limited lifespan (about 10 years), and repeat surgery is more likely
  • Suitable for older people
• Transcatheter aortic valve implantation (TAVI)
  • Has been used in people for whom other surgeries are not an option, but its role in the management of aortic regurgitation has not been formally established
• Clinical trials
  • Designed to improve the outcomes of people with cardiovascular disease
  • Provide people with access to future treatments that are not widely available

Eliminating risk factors affects the health of your aortic valve. Because aortic regurgitation develops over time, it is crucial to develop lifelong habits that protect your overall health and prevent chronic diseases, particularly those that contribute to aortic regurgitation.

Aortic incompetence can be managed with the following measures:

• Maintain normal blood pressure: Hypertension (high blood pressure) increases your risk of aortic regurgitation. It is estimated that 40% of people with aortic regurgitation have hypertension, which puts additional strain on your heart when it pumps blood. Additional stress may speed up the progression of aortic regurgitation and its complications, such as heart failure.
• Lower your cholesterol: High cholesterol and triglyceride levels in the blood increase the risk of aortic regurgitation. This is another chronic health condition that improves with lifestyle changes and medication.
• Stop smoking: Smoking significantly impacts the development of atherosclerosis in your coronary arteries. It is linked to an increased risk of aortic regurgitation. Talk to your doctor about smoking cessation programs or ask for medications to reduce cravings and symptoms associated with nicotine withdrawal.
• Prevent or control diabetes: Diabetes contributes to the progression of aortic regurgitation. It damages your heart valve by causing inflammation and promoting calcium buildup.
• Lifestyle changes:
  • Limit salt (sodium) intake
  • Cut back on caffeine (coffee, tea)
  • Practice stress reduction techniques
  • Do cardio exercises 
  • Avoid isometric and weightlifting exercises

Your doctor must check your heart regularly and if your symptoms have changed. Echocardiograms are frequently performed to determine whether the valve leakage has worsened or resulted in worsening heart function. 

When the valve leakage reaches a critical level, surgical intervention is required. In rare cases, the valve can be repaired, but in most cases, an artificial valve must be used to replace the leaking one.

The prognosis is better in cases of acute aortic insufficiency, but poor if the disease progresses. In severe aortic regurgitation, your doctor may recommend aortic valve replacement to improve the prognosis, but close monitoring is required. 

The treatment for aortic insufficiency tends to produce positive results. Monitoring your blood pressure and other symptoms and early examination can help prevent the disease from progressing. 

However, some complications do occur in people with aortic incompetence, including:

• Complications from valve replacement surgery
• Bacterial infection of the heart valves
• Heart failure
• Sudden cardiac death

About 85%-95% of people with mild to moderate aortic regurgitation will live another 10 years. However, within a few years of the onset of heart failure symptoms, there tends to be a rapid deterioration.