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Health condition · Clinically reviewed

Aortic regurgitation, a leaky valve, a stretched aorta - and when to act.

A common valve lesion that can be silent for years then decompensate quickly. Echo watches it, cardiac MRI measures it, and surgery has clear thresholds.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Clinically reviewed

    Written by our editorial team and reviewed by a registered UK clinician before publication.

  • 02

    Sourced from guidance

    Checked against ESC 2021, AHA/ACC 2020 valve guidelines and peer-reviewed cardiology sources.

  • 03

    Current for 2026

    Reflects modern UK practice including transthoracic echo, cardiac MRI quantification and valve-sparing root surgery.

Key facts

Aortic regurgitation at a glance.

The essentials, in plain English - what it is, what causes it, how it is measured and when it needs surgery.

  • What it is

    Aortic regurgitation (AR), also called aortic insufficiency, is leakage of blood back through the aortic valve into the left ventricle during diastole.

  • Two mechanisms

    Primary leaflet disease (bicuspid valve, endocarditis, rheumatic, degenerative) or aortic root and annulus dilation (hypertension, aneurysm, Marfan, dissection).

  • Chronic vs acute

    Chronic AR is often silent for years while the left ventricle enlarges. Acute AR from dissection or endocarditis is a surgical emergency.

  • How severity is set

    Echo grades mild, moderate or severe using vena contracta width, regurgitant volume and fraction, pressure half-time and LV dimensions.

  • Foundation imaging

    Transthoracic echo first, cardiac MRI for quantitative regurgitant volume and root sizing, CT aorta if root disease is suspected.

  • When to operate

    Symptomatic severe AR, or asymptomatic severe AR with LVEF 50 percent or less, LV end-systolic dimension over 50 mm, or a dilated aortic root.

Why this guide matters

Time the operation, not the symptoms.

The best AR outcomes come from timely imaging and clear surgical thresholds. The three points below shape everything else on this page.

  • Look at the valve and the aorta

    AR is often as much about the aortic root as the valve itself. Imaging should measure both, every time.

  • Silence is not safety

    Chronic AR can be symptom-free while the left ventricle enlarges. Serial echo detects the changes that matter.

  • Acute AR is an emergency

    Sudden severe AR from dissection or endocarditis is different in every way. Treat it like the surgical emergency it is.

How the diagnosis is made

From first murmur to a clear plan.

The steps a UK cardiologist will normally follow, in order - so you know what to expect and why each test is done.

  1. 01

    Assessing

    History and examination

    Exertional breathlessness, orthopnoea, angina and palpitations. Wide pulse pressure, water-hammer pulse and an early diastolic murmur at the left sternal edge.

  2. 02

    Assessing

    ECG, chest X-ray and BNP

    Baseline ECG for LV hypertrophy, CXR for cardiomegaly and pulmonary congestion, BNP or NT-proBNP for ventricular strain.

  3. 03

    Assessing

    Transthoracic echocardiogram

    The cornerstone test. Grades severity, measures LV dimensions and ejection fraction, and sizes the aortic root and ascending aorta.

  4. 04

    Confirming

    Transoesophageal echo if needed

    Used selectively when TTE images are limited, for suspected endocarditis, or before valve repair to characterise the leaflet mechanism.

  5. 05

    Confirming

    Cardiac MRI for quantification

    The gold standard for regurgitant volume and fraction, and for accurate aortic root and ascending aortic measurements.

  6. 06

    Confirming

    CT aorta and coronary assessment

    CT aortogram if root or ascending aortic disease is suspected. Coronary CT or invasive angiography before any planned valve or root surgery.

  7. 07

    Preparing

    Targeted extra tests

    Blood cultures and endocarditis workup if febrile. Genetic testing for connective tissue disease in the young or with root dilation.

Typical timeline: from first echo to a settled surveillance or surgical plan in weeks, not months.

Symptoms

What aortic regurgitation actually feels like.

The classic mix of breathlessness, angina and palpitations - and the peripheral signs that give AR away at the bedside.

  • Exertional breathlessness

    The commonest first symptom. Reduced exercise tolerance as the left ventricle can no longer compensate for the volume overload.

  • Orthopnoea and PND

    Breathlessness lying flat or waking from sleep gasping for air. A sign of raised left-sided filling pressures.

  • Angina at rest or on exertion

    Reduced coronary perfusion in diastole plus a hypertrophied ventricle can produce chest pain without coronary artery disease.

  • Palpitations and forceful beats

    Patients often notice a pounding heartbeat, particularly on lying down, from the large stroke volume of a leaky valve.

  • Wide pulse pressure

    A hallmark finding. High systolic and low diastolic pressures produce the classic bounding pulse of chronic AR.

  • Peripheral signs

    Corrigan water-hammer pulse, Traube pistol-shot femorals, de Musset head bobbing and Quincke pulsating nail beds.

  • Early diastolic murmur

    A soft, high-pitched decrescendo murmur best heard at the left sternal edge with the patient leaning forward in expiration.

  • Red flag - acute AR

    Sudden severe breathlessness, chest or back pain and cardiogenic shock. Think aortic dissection or acute endocarditis and act now.

Treatment

How aortic regurgitation is treated in the UK.

Watchful monitoring for mild disease, medication to support the ventricle and root, and clearly timed valve or aortic surgery for severe AR.

  • Watchful monitoring

    Asymptomatic mild or moderate AR with a normal-sized ventricle is followed with serial echo every 6 to 24 months, timed to severity.

  • Blood pressure control

    ACE inhibitors, ARBs or long-acting nifedipine reduce afterload in symptomatic patients or those with LV dilation who are not yet ready for surgery.

  • Losartan for aortic dilation

    In Marfan syndrome and related connective tissue disease, beta-blockers combined with an ARB such as losartan slow aortic root growth.

  • Endocarditis prevention

    Antibiotic prophylaxis before high-risk dental work for defined groups, plus scrupulous dental care to reduce bacteraemia.

  • Surgical aortic valve replacement

    Mechanical valves last for life but need warfarin. Bioprosthetic valves avoid warfarin but last 10 to 20 years and may need reoperation.

  • Aortic valve repair

    Selected patients with leaflet prolapse and a suitable anatomy can have valve-sparing repair, avoiding a prosthesis and long-term anticoagulation.

  • Root and ascending aorta surgery

    Bentall composite valve-and-graft or valve-sparing David root replacement when the aortic root or ascending aorta is significantly dilated.

  • TAVI and Ross procedure

    Transcatheter aortic valve implantation for high-risk elderly patients with suitable anatomy. The Ross procedure is an option in selected younger adults.

What this guide is based on

The sources behind every claim on this page.

UK national guidance and international valve society standards, current at the time of last review.

Key references

Guidelines and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

Your cardiologist knows your heart, your images and your history and can tell you which parts apply to you. If in doubt, get seen.

  • ESC/EACTS 2021 Guidelines for the management of valvular heart disease.

  • ACC/AHA 2020 Guideline for the management of patients with valvular heart disease.

  • NICE. Heart valve disease presenting in adults: investigation and management (NG208).

  • British Society of Echocardiography. Guideline for the echocardiographic assessment of aortic regurgitation.

Red flags

When aortic regurgitation needs urgent attention.

Most chronic AR is managed on scheduled clinic follow-up. These are the situations that are not, and where same-day input is needed.

  • Acute severe AR

    Sudden dyspnoea, hypotension and pulmonary oedema. Usually aortic dissection, endocarditis or trauma. Emergency surgery is often life-saving.

  • Aortic dissection

    Tearing chest or interscapular back pain with a new diastolic murmur. Immediate CT aortogram and cardiothoracic surgery review.

  • New murmur with fever

    Suspect infective endocarditis. Blood cultures, urgent echocardiogram and specialist infection and cardiology input are needed.

  • Progressive breathlessness

    Any fall in exercise tolerance in a patient with known AR warrants an urgent repeat echo and cardiology assessment.

  • Falling ejection fraction

    An LVEF drifting toward 50 percent, even without symptoms, is a strong signal to consider surgery before the ventricle decompensates.

  • Rapid aortic growth

    A root or ascending aorta growing by 3 mm or more per year, or exceeding surgical thresholds, needs prompt surgical review.

  • Syncope or near-syncope

    Loss of consciousness in severe AR is a serious sign. Urgent cardiology assessment is required to look for arrhythmia or advanced disease.

  • Marfan or Loeys-Dietz syndrome

    Connective tissue disease lowers the aortic diameter threshold for surgery. These patients need lifelong specialist follow-up.

  • Pregnancy with severe AR

    Pregnancy adds significant volume load. Pre-pregnancy counselling and joint obstetric and cardiology care are essential.

Living with it

A treatable condition, with a clear surgical ladder.

Four things that make the biggest difference day to day - keeping every scan, staying active within limits, protecting the valve from infection, and speaking up early about new symptoms.

A quiet reminder

Surveillance is the treatment, until it is not.

For chronic AR, keeping every echo appointment is what allows surgery to be offered at exactly the right moment.

  1. 01 Follow-up

    Keep every echo appointment

    Serial imaging is how surgeons pick the right moment to operate. Missed scans are the commonest reason to be too late.

  2. 02 Activity

    Stay active within limits

    Most people with mild or moderate AR can exercise normally. Heavy static lifting and competitive sport need individual advice for severe disease.

  3. 03 Dental

    Look after your teeth

    Good oral hygiene is one of the best defences against endocarditis. Tell every dentist you have valve disease.

  4. 04 Symptoms

    Flag any new breathlessness

    Do not wait for a routine appointment. Any new breathlessness, chest pain or fainting should trigger urgent review.

Frequently asked

Everything we get asked about aortic regurgitation.

Quick answers on causes, echo findings, surgical timing and valve choice.

  • What is aortic regurgitation?

    Aortic regurgitation, also called aortic insufficiency, is leakage of blood back through the aortic valve into the left ventricle during diastole. It can be caused by disease of the valve leaflets themselves or by dilation of the aortic root and annulus, and it can be chronic and slowly progressive or acute and life-threatening.

  • What causes aortic regurgitation?

    Primary leaflet causes include bicuspid aortic valve, rheumatic heart disease, infective endocarditis, degenerative calcific disease and leaflet prolapse. Aortic root and annulus dilation from hypertension, aortic aneurysm, aortic dissection, Marfan or Loeys-Dietz syndrome and ankylosing spondylitis can also stretch the valve and cause it to leak.

  • How is severity measured?

    A transthoracic echocardiogram grades AR as mild, moderate or severe using vena contracta width, regurgitant volume and fraction, pressure half-time under 200 milliseconds and left ventricular dimensions. Cardiac MRI is the most accurate way to quantify regurgitant volume and to size the aortic root.

  • What is the difference between acute and chronic AR?

    Chronic AR develops slowly. The left ventricle dilates and remodels, so patients can feel well for years before heart failure symptoms appear. Acute AR from aortic dissection, endocarditis or trauma gives the ventricle no time to adapt, so it presents with sudden pulmonary oedema and cardiogenic shock, usually needing emergency surgery.

  • When should the valve be replaced or repaired?

    Current ESC and AHA/ACC guidance recommends surgery for symptomatic severe AR, or for asymptomatic severe AR when the left ventricular ejection fraction falls to 50 percent or below, when the LV end-systolic dimension exceeds 50 mm (or an indexed value above 25 mm per square metre), or when the aortic root is significantly dilated - over 55 mm generally, and over 45 mm in Marfan syndrome with high-risk features.

  • What are the surgical options?

    The main options are mechanical valve replacement (durable but needing lifelong warfarin), bioprosthetic replacement (avoids warfarin but lasts 10 to 20 years), aortic valve repair for suitable prolapse, TAVI for high-risk elderly patients and the Ross procedure in selected younger adults. When the aortic root is also dilated, a Bentall composite valve-and-graft or a valve-sparing David root operation is used.

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