Aortic valve insufficiency

Disease Description (Causes and Symptoms)

• Definition/Pathophysiology: Aortic valve insufficiency (aortic regurgitation) is a condition in which the aortic valve does not close completely, causing blood to flow back from the aorta into the left ventricle during left ventricular diastole (the heart’s resting phase), resulting in left ventricular volume stress and volume overload. In acute cases, the left ventricle cannot compensate, causing diastolic pressure to rise rapidly and pulmonary edema and heart failure to develop quickly; in chronic cases, the left ventricle gradually enlarges, so symptoms appear late.
• Major causes: Degenerative valve changes, rheumatic valvular disease (formerly common), bicuspid aortic valve (congenital), aortic dissection or ascending aortic dilation (such as in Marfan syndrome), infective endocarditis, trauma, etc.
• Major symptoms: May be asymptomatic initially. Fatigue and shortness of breath during exertion → as the disease progresses, shortness of breath at rest, cough and sputum, chest pain, autonomic dysfunction (rare). In acute severe cases, acute shortness of breath, heart failure, and pulmonary edema.

Treatment Methods

• Diagnosis and monitoring: Echocardiography (transthoracic/transesophageal Doppler) is used to assess the severity of regurgitation, left ventricular size (left ventricular end-systolic diameter, LVESD; left ventricular end-diastolic diameter, LVEDD), left ventricular ejection fraction (LVEF), and accompanying valve or aortic lesions. If necessary, cardiac catheterization, cardiac MRI (quantification of volume and regurgitation fraction), BNP testing, electrocardiography, and chest X-ray may be performed.
• Medication treatment
  • Chronic compensated mild-to-moderate AR: Special medication is often not required. If hypertension is present, reducing left ventricular burden with antihypertensive drugs such as ACE inhibitors or ARBs may be considered.
  • When symptoms of heart failure are present: Diuretics, ACE inhibitors/ARBs, beta-blockers (depending on the situation), and standard heart failure treatment according to symptoms may be used.
  • Acute severe AR: In cases of hemodynamic instability, reduce afterload with intravenous vasodilators (e.g., nitroprusside) and, if necessary, stabilize the patient before surgery with supportive drugs such as dobutamine (definitive treatment is emergency surgery).
• Procedures/Surgery
  • Indications: Surgery is recommended for symptomatic severe AR or, even if asymptomatic, when there is left ventricular enlargement or dysfunction, such as reduced left ventricular function (LVEF ≤50%) or LVESD >50 mm (or exceeding the indexed criteria). Acute severe AR requires emergency surgical treatment.
  • Types of surgery: Valve repair — valve preservation and repair when possible. Valve replacement — removal of the damaged valve and insertion of an artificial valve.
    • Bioprosthetic valve (tissue valve): Lower dependence on anticoagulants and lower bleeding risk, but limited durability (with the possibility of reoperation after approximately 10 years or more).
    • Mechanical valve: Excellent durability, but lifelong anticoagulation (warfarin) is required and the risk of bleeding increases.
• Lifestyle management and precautions (self-care)
  • Blood pressure management: Maintain the target blood pressure and take antihypertensive medication if necessary.
  • Low-salt diet and weight management: Limit salt to control edema and blood pressure, and maintain a normal weight.
  • Exercise: Follow the doctor’s instructions according to the recovery period, symptoms, and surgical status; regular light aerobic activity is recommended, but excessively strenuous exercise should be limited.
  • Anticoagulation management: With a mechanical valve, lifelong warfarin use and periodic INR testing and adjustment are necessary (the target INR varies according to the type and location of the valve and accompanying risk factors → consult the attending physician).
  • Endocarditis prevention: For people with an artificial valve or a history of endocarditis, prophylactic antibiotics before dental or invasive procedures are recommended (follow clinical guidelines).
• Complications: Progressive deterioration of left ventricular diastolic and systolic function, heart failure, pulmonary edema, infective endocarditis, arrhythmia, and worsening associated with the aortic loop and dissection.
• Prognosis: Varies depending on the stage, severity, and timing of surgery. Chronic compensated cases with controlled disease may remain asymptomatic for a long time; if surgery is delayed, recovery of left ventricular function after surgery may be limited and the prognosis may be poor.

Checklist Before an Outpatient Visit (Items to Prepare, Records, and Example Questions)

• Items/information to bring
  • A list of all currently used medications (dosage and administration times), including supplements and herbal medicines
  • Copies of previous heart-related test results (echocardiography images and findings, electrocardiogram, chest X-ray, blood tests, etc.), if possible
  • A record of recent symptom changes (shortness of breath during exertion, chest pain, fainting, nighttime shortness of breath, etc.), including when they began, frequency, and triggers
  • Weight and blood pressure records (if values measured at home are available)
  • If taking anticoagulants, the latest INR result and date of testing
  • History of previous surgery or infective endocarditis, and whether valve surgery or replacement has been performed
• What to show the doctor during the outpatient visit
  • Medication list, recent echocardiography and test results, symptom diary, and INR records (if applicable)
• Example questions before the consultation (for patients to check themselves)
  • Are my symptoms getting worse? (Has shortness of breath during exertion increased? Do I have shortness of breath at rest?)
  • Do I experience fatigue or dizziness during light activity?
  • Have I had any episodes of chest pain or fainting?

Examples of General Questions to Ask the Doctor

• How severe is my current condition (mild/moderate/severe)? How should the echocardiography values (LVESD, LVEDD, LVEF) be interpreted?
• Do I meet the indications for surgery (valve replacement/repair)? When would be the appropriate time for surgery?
• What are the expected benefits and side effects of medications (e.g., ACE inhibitors, ARBs, and diuretics)?
• If I need to choose an artificial valve, which would you recommend: a mechanical valve or a bioprosthetic valve? What are the advantages and disadvantages of each option, and how would they affect daily life (pregnancy plans, anticoagulants, etc.)?
• At what intervals should I have regular follow-up tests (echocardiography)?

Examples of Disease-Specific Questions

• What are my respective LVESD/LVEDD/LVEF values on my latest echocardiogram? Do these values meet the indications for surgery (e.g., LVESD >50 mm or LVEF ≤50%)?
• If I experience acute worsening (e.g., sudden shortness of breath or pulmonary edema), what emergency treatment should I expect to receive at the hospital immediately (vasodilators, surgery, etc.)?

(Note: The information above is general medical information. Individual treatment decisions should be made in consultation with the attending cardiologist and cardiac surgeon.)