Aortic Valve Regurgitation: Treatment Overview

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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 medications. 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 (Apresoline). These medications, 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.⁴

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 medication and therapy to help you quit smoking. Studies show that the combination of nicotine replacement therapy, use of the medication bupropion (Zyban or Wellbutrin), and supportive therapy significantly increases long-term success in quitting.⁵ For more information, see the topic Quitting Tobacco Use.
• 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. Exercise for at least 30 minutes on most, preferably all, days of the week.
• 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.²

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 once your ejection fraction drops below 50% or your left ventricle enlarges to more than 55 millimeters at rest. Many people do not have any symptoms at this point, because symptoms typically only occur after the condition has progressed to the point that it has already damaged the heart.²

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 medications, 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 (Apresoline). These medications, 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.⁴

If aortic valve regurgitation causes chest pain, medications called nitrates (nitroglycerin) can sometimes be tried to help relieve the pain. Antiarrhythmic medications may be needed if aortic valve regurgitation leads to abnormal heart rhythms (arrhythmias). If aortic valve regurgitation causes heart failure, medications 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. Exercise for at least 30 minutes on most, preferably all, days of the week. 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. The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend having aortic valve replacement surgery once your ejection fraction drops below 50% or your left ventricle enlarges to more than 55 millimeters at rest. Many people do not have any symptoms at this point, because symptoms typically only occur after the condition has progressed to the point that it has already damaged the heart.²

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

If you begin to develop symptoms from aortic valve regurgitation, your doctor will also recommend surgery. After you develop symptoms, aortic valve replacement surgery is the only cure for aortic regurgitation.

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.

If you have an artificial valve, getting an infection in your heart (endocarditis) could be very dangerous for you. To prevent an infection, you may need to take antibiotics before you have certain dental or surgical procedures.

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.

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Last updated:	February 01, 2006
Author:	Merrill Hayden
Reviewed By:	Caroline S. Rhoads, MD - Internal Medicine, Stephen Fort, MD, MRCP, FRCPC - Interventional Cardiology
Editors:	Kathleen M. Ariss, MS, Terrina Vail