Skip to main content
Download PDF

Echocardiographic assessment of aortic regurgitation: a narrative review

Echo Research & Practice volume 11, Article number: 1 (2024) Cite this article

Abstract

Aortic regurgitation (AR) is the third most frequently encountered valve lesion and may be caused by abnormalities of the valve cusps or the aorta. Echocardiography is instrumental in the assessment of AR as it enables the delineation of valvular morphology, the mechanism of the lesion and the grading of severity. Severe AR has a major impact on the myocardium and carries a significant risk of morbidity and mortality if left untreated. Established and novel echocardiographic methods, such as global longitudinal strain and three-dimensional echocardiography, allow an estimation of this risk and provide invaluable information for patient management and prognosis. This narrative review summarises the epidemiology of AR, reviews current practices and recommendations with regards to the echocardiographic assessment of AR and outlines novel echocardiographic tools that may prove beneficial in patient assessment and management.

Introduction

Aortic regurgitation (AR) may be secondary to abnormalities of the AV leaflets, the structure or geometry of the aortic root or the ascending aorta, or a combination of the two. AR may develop acutely or present as a chronic process, and results in diastolic blood flow reversal from the aorta to the left ventricle (LV) [1]. AR is the third most common native valvular heart disease behind aortic stenosis and mitral regurgitation with a prevalence of approximately 0.5% of the total population, increasing to almost 15% of individuals over the age of 65 [2, 3]. Furthermore, severe AR accounts for around 5% of all native valve intervention [4, 5]. With an ageing population, it is expected that healthcare professionals will encounter patients with AR increasingly frequently in clinical practice.

Severe AR is an important cause of morbidity and mortality. Left untreated, the risk of death is approximately one third over 10 years, and almost a half of all patients will develop heart failure [6, 7]. Even in asymptomatic patients, severe AR carries a noteworthy annual mortality risk of up to 2.2% [7, 8]. Echocardiography is central to the diagnosis and quantification of AR severity, in addition to delineating the aetiology and mechanism of valve insufficiency. Echocardiography is also key in the characterisation of important prognostic features including left ventricular (LV) dimensions and function, which may influence patient management. This narrative review summarises epidemiology and aetiology of AR, the evidence-base regarding echocardiographic assessment of aortic insufficiency, and novel echocardiographic tools that may prove beneficial in patient assessment and management.

Aetiology of aortic regurgitation

AR may present and/or develop acutely or gradually and is caused by malcoaptation or malapposition of the AV cusps. This may be a result of abnormalities of the AV cusps and/or their supporting structures, including the AV annulus, the aortic root and the ascending aorta [9]. In Western countries, degenerative AV disease is the most common cause of AR, accounting for approximately half of the total cases [4]. Degenerative AV disease is more frequently encountered in the form of focal calcific deposits or diffuse fibrous thickening causing abnormal coaptation, although, rarely, myxomatous degeneration of the aortic cusps may also account for AR secondary to cusp thickening and/or prolapse [10]. Apart from myxomatous degeneration, aortic valve prolapse itself accounts for approximately 1.2% of all diagnosed AR lesions and may be encountered in patients with bicuspid AV and patients with aortic root disease, such as dissection or dilatation [11]. Rheumatic fever is the leading cause of AR in developing countries, and despite widespread use of antibiotics remains a notable cause of AR in Western countries alongside bicuspid aortic valve disease and infective endocarditis [4].

AR may also be a result of distortion of the structures that support the cusps and loss of support from the annulus, root and aorta. Minor dilatation of the ascending aorta occurs with ageing, a process mediated by cystic medial degeneration that weakens the aortic wall [12, 13]. However, this physiological process is commonly accelerated by the presence of hypertension, which leads to increased wall stress [12, 14]. Atherosclerosis may result in dilatation of the aorta, although this process is usually reserved to the descending rather than the ascending aorta [12]. A dilated ascending aorta is frequently seen to co-exist in patients with bicuspid AV and connective tissue disorders [12, 15]. Less commonly, AR may be caused by aortic dilatation and aortic root aneurysms associated with inflammatory changes in the aortic wall secondary to large vessel vasculitis and rheumatic diseases [16]. Rarely, congenital ventricular septal defects (VSDs), especially perimembranous or subarterial types of VSD, may lead to aortic valve prolapse and regurgitation as a result of loss of cusp structural support and the Venturi effect [17, 18]. Approximately half of subarterial VSDs with associated AV prolapse are complicated by AR therefore preventative early surgery is recommended, whilst for perimembranous VSDs with concomitant AV prolapse, surgery is recommended if more than trivial AR develops [18, 19].

Table 1 summarises the causes of acute and chronic aortic regurgitation.

Table 1 Causes of acute and chronic aortic regurgitation
Full size table

Echocardiographic assessment of aortic regurgitation

Mechanism and classification of AR

Originally designed for the mitral valve, Carpentier’s classification has been adapted for use in the assessment of AR mechanism, whereby the lesion is classified according to cusp morphology and motion [20, 21]. Type I includes AR with normal cusp motion, where the insufficiency is secondary to aortic root dilatation or cusp perforation; Type II AR refers to excessive cusp motion including aortic cusp prolapse; those with restricted cusp motion are grouped in type III [21] (Table 2). The functional classification is an invaluable tool that helps clinicians systematically evaluate the valve behaviour and may influence the type of intervention chosen for the valve [22, 23]. It also carries prognostic value both in terms of valve repairability and of long-term outcomes: Type III AR is associated with poorer long-term outcomes after valve sparing surgery and a higher risk of recurrent AR post valve repair [23,24,25]. Cusp perforation/fenestration is another important phenotype that has important implications for the choice of surgical treatment, as it has less favourable outcomes when treated with valve repair [25, 26].

Table 2 Anatomical classification of AR lesions according to cusp motion
Full size table

The degree of AV calcification may influence clinical decision making, and a grading system has been proposed: no calcification is classed as grade 1; small calcification spots (grade 2); larger calcification spots interfering with cusp motion is grade 3; extensive calcification causing restricted cusp motion is grade 4 [20]. Valve sparing or valve repair surgery is not recommended in cases with moderate or extensive cusp calcification (grades 3 & 4), due to the substantial risk of recurrence of significant AR post valvuloplasty [25, 27].

Three-dimensional (3D) echocardiography may provide additional useful information, by enabling the reconstruction, visualisation and assessment of the morphology of the AV without the geometrical assumptions involved in 2D echocardiography [28, 29]. Multi-plane imaging of the AV removes the uncertainty of the single cut-plane position in the parasternal view, allowing correct identification of all the aortic cusps [29]. It is also beneficial for visualisation of the AV throughout the cardiac cycle, overcoming the issue of through-plane motion [29]. However, 3D echocardiographic assessment of the AV is challenging and often suboptimal in cases of significant AV calcification or in patients with poor acoustic windows [28, 29].

Severity of AR

Doppler assessment including colour flow and continue wave (CW) Doppler allow detailed assessment and visualisation of the aortic regurgitant jet and its components including the flow convergence zone, the vena contracta (VC) and the jet area [21, 30]. Assessment of these characteristics constitute the primary method of evaluation of the severity of AR [20, 21].

A simple visual assessment of the CW signal density may provide a general idea of the severity of the AR; a denser CW Doppler signal indicating more regurgitant flow and a faint signal suggesting mild regurgitation. Beam alignment is an important issue when using this method, with eccentric jets resulting in faint signals because of the Doppler error stemming from the large angle of insonation. Importantly, both moderate and severe AR result in dense CW traces; ultimately, due to the these limitations, CW signal density is not recommended to be used to quantify AR [30].

A small study demonstrated that jet width, defined as the ratio of the jet diameter divided by the Left Ventricular Outflow Tract (LVOT) diameter, correlated well with the angiographically obtained grade of AR severity: a ratio of ≥ 65% being consistent with severe AR [31]. However, very few patients were included in this study, none of whom had congenital AV disease or AR type II, limiting its value in such circumstances [31]. Subsequent work has questioned the usefulness of this parameter, which has less physiological significance than the VC, even when normalising for the LVOT diameter [32]. As such, current guidelines advocate the use of jet width as part of a multiparametric assessment of AR [21, 30]. Jet length and jet area are very much dependent on LV compliance and diastolic pressure, and do not reflect the severity of the AR; accordingly they are not recommended for use [33].

Interpretation of colour Doppler is challenging in acute severe AR. In such cases, LV diastolic pressure rises rapidly as the non-compliant LV fills with blood from both the aorta and the left atrium during diastole [20, 21, 33]. This results in the AR jet being of shorter duration and lower velocity, becoming therefore difficult to detect with colour flow Doppler only. In these cases, other echocardiographic methods should be used for the assessment of the AR severity [21, 30].

Pressure half-time (PHT) is a technique in which the rate of deceleration of the regurgitant blood flow can be measured from the CW Doppler of the AR. As AR becomes more severe, LV end-diastolic pressure increases and end-diastolic aortic pressure decreases, resulting in a smaller late diastolic gradient and therefore shorter pressure half-time [36]. Early work demonstrated that a PHT of 400ms can reliably identify important regurgitation, and angiographic grade 4 + AR correlates with a PHT of approximately 200ms [35]. Multiple subsequent reports confirm that mild AR demonstrates significantly longer PHT compared to moderate to severe AR [36,37,38]. There are several important drawbacks of this technique. First, it is challenging in eccentric jets in which optimised alignment of the US beam is often not possible. Secondly, correlation between the pressure half-time and severity of AR is poor in mild or moderate AR, but better in severe AR cases [34, 35, 38]. A third concern is that PHT is highly influenced by the diastolic function of the LV, with the measurement becoming unreliable in cases of impaired relaxation and/or compliance and significant co-existent LVH [39]. Finally, changes in the diastolic blood pressure secondary to medications (i.e., vasodilators) can also affect the gradient between the aorta and the LV, rendering the method less useful in patients on those medications [40]. Acknowledging these limitations, the PHT is recommended to be used as a supplementary method of assessment and grading of the AR should not rely solely on this [21, 30].

In mild AR, early flow reversal may be seen in the proximal descending thoracic aorta. As the severity of AR progresses, the duration of flow reversal extends through diastole with the reversal velocity of the blood increasing [30]. In a small study, holodiastolic flow reversal with end-diastolic velocity of ≥ 20cm/s was found to be a marker of severe AR and correlated well with a regurgitant fraction (RF) of ≥ 40% with a sensitivity and specificity of 88% and 96% respectively [30, 41]. MRI studies have confirmed the highly specific nature of this finding for severe AR [42, 43]. Colour-coded M-mode may help in the assessment of the timing of the flow signal in relation to the cardiac cycle [30]. Holodiastolic flow reversal in the abdominal aorta is also a highly specific marker of severe AR, but with moderate sensitivity [44, 45]. This sign is also commonly found in patients with congenital heart disease and aorto-pulmonary shunt, therefore, its presence on these occasions is not highly specific for severe AR [46, 47].

The VC represents the smallest flow diameter of the regurgitant jet going through the AV, and provides a surrogate for the effective regurgitant orifice area (EROA) and an indicator of the AR severity [30]. A number of studies have reported that a VC of > 5mm correlates with severe AR with a sensitivity up to 95% and specificity between 80 and 90%, making it an excellent tool in the identification of severe AR [32, 48]. The main limitations of VC include the assumption of a circular regurgitant orifice, which is often not the case. Additionally, there are no studies investigating the accuracy or prognostic role of VC in the context of multiple AR jets: in such cases guidelines advocate that the VC of the largest jet should be reported, acknowledging that this will necessarily underestimate overall severity of AR [30]. This is an important limitation for clinical use.

Although qualitative assessment of AR is used more frequently in echocardiographic practice, quantitative measures provide the clinician with prognostic information which may inform management. The proximal isovelocity surface area (PISA) method directly assesses the EROA and can be used to the derive the regurgitant volume (RV). The ratio of forward flow or stroke volume to RV can be used to determine the regurgitant fraction (RF). An EROA ≥ 0.30cm2, regurgitant volume ≥ 60mls and regurgitant fraction > 50% all indicate severe AR [20].

In a study of over 250 asymptomatic patients with chronic severe AR, EROA and RV were shown to be independent predictors of 10-year survival and freedom from surgery from AR [8]. In a smaller analysis, integrated assessment and quantification of AR severity closely correlated with the clinical endpoint of AV surgery [49].

Despite the prognostic value of these tools, the PISA method can be challenging with substantial cusp thickening and/or calcification influencing the visible convergence zone. Additionally, the EROA appears to be significantly underestimated when there is an obtuse flow convergence zone angle (> 220°) [50]. In the presence of eccentric jets, PISA tends to underestimate AR severity although these limitations can be overcome when the assessment is performed from the left parasternal instead of the apical window [51].

The calculation of the regurgitant volume requires the VTI obtained from the CW Doppler envelope of the regurgitation, which may be challenging to obtain in eccentric jets when alignment of the US beam is difficult. Regurgitant volume can also be derived by calculating the difference in the stroke volume through the LVOT and the mitral valve inflow. This method is time-consuming, can only be applied if there is no significant co-existent mitral or pulmonary regurgitation, and is subject to significant inter-observer variability and errors in linear dimensions that may substantially impact on the final result [20].

In cases of acute AR or when LV is impaired and there is reduced LV stroke volume, both the EROA and the regurgitant volume may underestimate the severity of AR: in such circumstances, the RF may be more useful at indicating severe AR [30]. Early mitral valve closure and diastolic mitral regurgitation (MR) are important echocardiographic signs that may alter the clinical course and management of patients with acute severe AR. Premature closure of the mitral valve may be categorised as grade I (up to 50ms before the Q wave) or as grade II (up to 200ms before the Q wave) and is a specific and sensitive indicator of acute severe AR [52]. Patients with grade II early mitral valve closure usually suffer significant elevations in their LV diastolic pressure and volume which cannot be adequately compensated [52]. Therefore, their presence suggests urgent surgical intervention [52, 53]. In addition, the presence of diastolic mitral regurgitation is an independent predictor of pulmonary oedema and/or haemodynamic instability in patients with acute severe AR and therefore is another echocardiographic finding that may play an important role in patient’s management plan and prognosis [54].

In summary, a quantitative assessment of AR should be routinely performed for those patients with more than mild AR [20, 21, 30]. Additional parameters are useful if there is disagreement between these parameters and to corroborate the conclusion of quantitative assessment. Of the additional techniques, diastolic flow reversal in the descending aorta is the strongest parameter for the evaluation of the severity of AR [20]. Table 3 summarises the echocardiographic indicators of severe AR as per the American and European guidelines.

Table 3 Markers of severe Aortic Regurgitation (AR) according to international guidelines
Full size table

An algorithmic approach and hierarchical weighting of key echocardiographic parameters may be extremely helpful when grading the severity of AR [55]. Multiparametric assessment, as recommended by the current international guidelines, is a useful approach in the evaluation of the AR severity, however it increases the risk of interobserver variability of AR assessment and leads to significant inconsistencies between the assessors. This phenomenon becomes more pronounced in the presence of discordant parameters [55]. Preferential weighting of selected echocardiographic parameters may overcome this important limitation. Using a practical algorithm based on parameters both useful and highly influential when grading the severity of AR, minimises interobserver variability and improves concordance and accuracy [55]. Each of the echocardiographic parameters in isolation may have several limitations that make the grading of AR severity challenging and problematic. A practical algorithmic approach that incorporates not only a certain number of parameters but also the significance of each parameter, can help overcome this challenge and adopt a consistent and accurate method of assessing AR severity.

Haemodynamic consequences of AR

Chronic severe AR has important haemodynamic consequences that affect the LV size and function. Long-standing volume overload results in LV remodelling, which ultimately results in maladaptive changes to the myocardium, decline of LV function and the development of symptoms [57]. Multiple studies have shown that increased LV size and impaired systolic function are independently associated with adverse events and poor long-term survival [58,59,60,61,62,63,64,65,66,67,68]. AV surgery is therefore a Class I recommendation for patients with severe AR and impaired LV systolic function (LVEF ≤ 50%) or significantly dilated LV (LV end-systolic diameter > 50mm, indexed LV end-systolic diameter > 25mm/m2 or LV end-diastolic diameter > 65mm), even in the absence of symptoms [69].

Indexed LV end-systolic diameter (LVESDi) is an indicator of LV volume overload and systolic shortening. In a study of 1,417 patients with severe AR and minimal or no symptoms, there was a significant increase in mortality with an LVESDi > 20 mm/m2, a markedly lower cut-off than the guideline-recommended surgical threshold [6]. This cut-off value was confirmed by two further observational studies with a total combined population of more than 1000 patients [70, 71]. In another study of 284 patients, LVESD ≥ 45 mm was found to be an independent predictor of postsurgical mortality [72]. The LVEF threshold has also been challenged: observational studies suggest that 10-year mortality rates and adverse events are significantly higher in patients with an LVEF ≤ 55% when compared to those patients with an LVEF > 55% [63, 70]. Acknowledging the importance of these data, ESC guidelines suggest the consideration of surgery when LVESDi > 20 mm/m2 or LVEF < 55% as class IIb recommendation in low-risk cases [69]. Volumetric assessment of the left ventricle has also been shown to be significant, with several studies demonstrating that indexed LV end-systolic volume (LVESVi) of 45 mL/m2 or greater is significantly associated with an increased risk of mortality and adverse events [67, 68, 73]. In fact, there is evidence to suggest that the prognostic significance of LVESVi with mortality is stronger than that of the linear dimensions [73].

For patients with severe AR who do not meet the currently recommended criteria for surgery, regular echocardiographic monitoring is recommended, as serial changes in LV function and dimensions may identify those that are most likely to develop symptoms and need operation in the near future [56, 69, 71]. Asymptomatic patients with moderate and severe AR should have echocardiographic assessment on an annual basis, whilst those approaching the thresholds for intervention should be followed up at 3–6 monthly intervals [69, 74]. For patients with mild-to-moderate AR, echocardiographic assessment every 2–3 years is a reasonable timeline of surveillance [69, 74].

LV size and function is of high importance for patients’ post-surgical mortality and morbidity [64, 75]. Significant LV dilatation and severely reduced LV systolic function (defined as LVEF < 35%) are associated with poor postoperative short- and long-term outcomes [65, 76]. Smaller baseline indexed LV systolic and diastolic dimensions are associated with early recovery of the LV systolic function after valve surgery [77]. Furthermore, a study with 69 patients who underwent AVR for severe AR demonstrated that postoperative reverse remodelling is associated with better 10-year outcomes and survival rates [78]. Table 4 summarises the main findings of the studies that have examined the prognostic significance of LV structural and functional remodelling parameters in patients with AR.

Table 4 Studies that have examined the significance of left ventricular structural and functional remodelling in aortic regurgitation (in chronological order)
Full size table

Given its significant prognostic value, echocardiographic assessment of the LV is of paramount importance in the evaluation and management of patients with aortic regurgitation not only before but also after they have AV surgery.

Novel echocardiographic indices

3D transthoracic echocardiography facilitates advanced assessment of the valve anatomy and severity of the regurgitation. 3D interrogation allows delineation of anatomical features of the AV and nearby structures, such as inter-commissural distance and aortic annular diameter, that may be used for preoperative planning [29, 87]. As mentioned previously, a major limitation of the VC method is the assumption of a circular regurgitant orifice. 3D colour Doppler echocardiography allows visualisation of the VC in simultaneous orthogonal views and enables an assessment of the cross-sectional area of the VC [88]. This method has been shown to correlate well with Cardiac Magnetic Resonance (CMR) imaging, aortographic and surgical grading of AR severity [43, 88]. A number of small studies have suggested differing cut-off values for 3D VC, ranging from 30mm2 to 60mm2 that correspond with severe AR [88,89,90,91]. As yet, there is no outcome data for 3D VC, therefore further validation is required before it is widely incorporated into practice.

Myocardial deformation or strain imaging may allow the identification of subclinical myocardial impairment present even with a normal LVEF. LV global longitudinal strain (GLS) is significantly reduced in patients with severe AR and otherwise normal LVEF [92, 93]. Several observational studies have demonstrated that GLS is an independent predictor of mortality in patients with severe AR [94,95,96,97]. A recently published systematic review reports that worse values of GLS are associated with poor cardiovascular outcomes [98]. Owing to marked heterogeneity between the studies in the analysis, most of which included fewer than 100 patients, no specific threshold value of GLS could be identified that may be of clinical use, but certainly further investigation is warranted in this regard. In a large observational study including over 1000 patients with chronic asymptomatic severe AR, GLS was independently associated with 5-year all-cause mortality [96]. Interestingly all deaths in this study occurred in patients who did not meet criteria for intervention according to the current guidelines. The reasons for this are not clear, but the authors suggest that reliance on conventional tools in the assessment of LV remodelling are likely inadequate in an overall assessment of cardiovascular risk [96]. GLS has a prognostic value postoperatively, with impaired GLS values both immediately following surgery and persistently after intervention being associated with increased long-term mortality [95, 99].

Strain imaging is not limited to the LV. Left atrial (LA) reservoir strain has been documented to be impaired in patients with chronic asymptomatic severe AR, but lower values of LA strain are associated with adverse prognosis, and show promise in risk stratification of patients with severe AR [100,101,102]. Figure 1 provides a summary of all the parameters of significance in the echocardiographic assessment of AR (Fig. 1).

Fig. 1
figure 1

Summary of key echocardiographic parameters for the assessment of Aortic Regurgitation (AR)

Full size image

An extremely novel approach is to assess cardiac mechanics with strain-volume loops, which may allow a deeper understanding into the haemodynamic consequences of AR. Whereas LVEF and strain do not necessarily distinguish between LV remodelling in valve disease and normal controls, strain-volume loops were significantly better at identifying adverse LV remodelling compared to the conventional echocardiographic approach [103].

Table 5 provides a summary of the studies that have investigated the role of strain parameters in AR.

Table 5 Studies evaluating the role of strain parameters in aortic regurgitation (in chronological order)
Full size table

Future directions

Whilst current guidance is frequently derived from an evidence-base that consists of small studies conducted more than two decades ago, the future holds promise with a series of robust studies that will hopefully complement the current data, and improve the echocardiographic assessment of AR. Larger prospective studies have already set out to answer several questions around the established and novel echocardiographic parameters used and their potential additive value in risk stratification and management of these patients.

The ‘Early Aortic Valve Surgery Versus Watchful Waiting Strategy in Severe Asymptomatic Aortic Regurgitation’ (ELEANOR) study (NCT05438862) is a prospective randomised trial investigating optimal timing of surgical intervention in asymptomatic patients with severe AR. Patients are randomised to watchful waiting approach with guideline-indicated intervention, or to early surgery. Participants undergo echocardiographic and other advanced imaging assessments at regular follow-up intervals. This study should provide insight into the prognostic value of echocardiographic parameters and how these identify patients’ clinical trajectory and adverse events.

Another upcoming study is the ‘Comparative Imaging Assessment of Valvular Heart Disease’ prospective observational study (NCT04126018) is investigating the accuracy of 2D and 3D echocardiographic methods of valvular quantification and is due to complete recruitment in 2023. Approximately 40 participants with moderate or severe valvular lesions, including AR, aortic stenosis and mitral regurgitation, will undergo 2D and 3D transthoracic echocardiographic studies. Conventional echocardiographic tools including Doppler, PISA, VC and volumetric method, will be compared to the reference standard of CMR, and will correlate with clinical outcomes.

Conclusion

Aortic regurgitation is a common valvular heart disease with significant impact on patient mortality and morbidity. Echocardiography is a simple, yet invaluable, tool in the assessment of the morphology, mechanism and severity of the regurgitation. It provides important information about the impact of the lesion on the myocardium, adding prognostic data that influences patient management and treatment strategy. The use of advanced echocardiographic methods allows more precise quantification of regurgitation and estimation of subclinical myocardial dysfunction. Future studies that investigate the benefit of established and novel methods and link to clinical outcomes will improve our understanding of aortic regurgitation and enable improved clinical practice.

Availability of data and materials

All data presented in this manuscript are already published data that are publicly available and are cited throughout the document.

References

  1. Sallach SM, Reimold SC. Echocardiographic evaluation of aortic regurgitation. In: Solomon SD, Bulwer B, editors. Essential echocardiography. Totowa: Humana Press; 2007.

    Google Scholar 

  2. D’Arcy JL, Coffey S, Loudon MA, Kennedy A, Pearson-Stuttard J, Birks J, et al. Large-scale community echocardiographic screening reveals a major burden of undiagnosed valvular heart disease in older people: the OxVALVE population cohort study. Eur Heart J. 2016;37(47):3515–3522a.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Nkomo VT, Gardin JM, Skelton TN, Gottdiener JS, Scott CG, Enriquez-Sarano M. Burden of valvular heart diseases: a population-based study. Lancet. 2006;368(9540):1005–11.

    Article  PubMed  Google Scholar 

  4. Iung B. A prospective survey of patients with valvular heart disease in Europe: the Euro heart survey on valvular heart disease. Eur Heart J. 2003;24(13):1231–43.

    Article  PubMed  Google Scholar 

  5. Iung B, Delgado V, Rosenhek R, Price S, Prendergast B, Wendler O, et al. Contemporary presentation and management of valvular heart disease: the EURObservational research programme valvular heart disease II survey. Circulation. 2019;140(14):1156–69.

    Article  PubMed  Google Scholar 

  6. Mentias A, Feng K, Alashi A, Rodriguez LL, Gillinov AM, Johnston DR, et al. Long-term outcomes in patients with aortic regurgitation and preserved left ventricular ejection fraction. J Am Coll Cardiol. 2016;68(20):2144–53.

    Article  PubMed  Google Scholar 

  7. Dujardin KS, Enriquez-Sarano M, Schaff HV, Bailey KR, Seward JB, Tajik AJ. Mortality and morbidity of aortic regurgitation in clinical practice. A long-term follow-up study Circulation. 1999;99(14):1851–7.

    CAS  PubMed  Google Scholar 

  8. Detaint D, Messika-Zeitoun D, Maalouf J, Tribouilloy C, Mahoney DW, Tajik AJ, et al. Quantitative echocardiographic determinants of clinical outcome in asymptomatic patients with aortic regurgitation: a prospective study. JACC Cardiovasc Imaging. 2008;1(1):1–11.

    Article  PubMed  Google Scholar 

  9. Bekeredjian R, Grayburn PA. Valvular heart disease: aortic regurgitation. Circulation. 2005;112(1):125–34.

    Article  PubMed  Google Scholar 

  10. Abdelazeem B, Hollander RM, Gresham TM, Gjeka R, Kunadi A. Aortic valve insufficiency due to myxomatous degeneration: a case report and literature review. AME Case Rep. 2022;6:10–10.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Shapiro LM, Thwaites B, Westgate C, Donaldson R. Prevalence and clinical significance of aortic valve prolapse. Br Heart J. 1985;54(2):179–83.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Isselbacher EM. Thoracic and abdominal aortic aneurysms. Circulation. 2005;111(6):816–28.

    Article  PubMed  Google Scholar 

  13. Kou S, Caballero L, Dulgheru R, Voilliot D, De Sousa C, Kacharava G, et al. Echocardiographic reference ranges for normal cardiac chamber size: results from the NORRE study. Eur Heart J Cardiovasc Imaging. 2014;15:680–90.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Cozijnsen L, Braam RL, Waalewijn RA, Schepens MAAM, Loeys BL, van Oosterhout MFM, et al. What is new in dilatation of the ascending aorta? Circulation. 2011;123(8):924–8.

    Article  PubMed  Google Scholar 

  15. Nataf P. Dilation of the thoracic aorta: medical and surgical management. Heart. 2006;92(9):1345–52.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Tyagi S, Safal S, Tyagi D. Aortitis and aortic aneurysm in systemic vasculitis. Indian J Thorac Cardiovasc Surg. 2019;35(S2):47–56.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Kumari V, Shaikh AS, Zakai SB, Kumar N, Bangash SK, Patel N, et al. Incidence of Aortic Regurgitation in Association with Type of Ventricular Septal Defects and its Immediate and Intermediate Outcome after Surgical Closure. Cureus. 2019 Jul 8;11(7). https://www.cureus.com/articles/20353-incidence-of-aortic-regurgitation-in-association-with-type-of-ventricular-septal-defects-and-its-immediate-and-intermediate-outcome-after-surgical-closure. Accessed 13 Sep 2023.

  18. Tweddell JS, Pelech AN, Frommelt PC. Ventricular septal defect and aortic valve regurgitation: pathophysiology and indications for surgery. Sem Thorac Cardiovasc Surg Pediatr Cardiac Surg Ann. 2006;9(1):147–52.

    Article  Google Scholar 

  19. Tohyama K, Satomi G, Momma K. Aortic valve prolapse and aortic regurgitation associated with subpulmonic ventricular septal defect. Am J Cardiol. 1997;79(9):1285–9.

    Article  CAS  PubMed  Google Scholar 

  20. Lancellotti P, Tribouilloy C, Hagendorff A, Popescu BA, Edvardsen T, Pierard LA, et al. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European association of cardiovascular imaging. Eur Heart J Cardiovasc Imaging. 2013;14(7):611–44.

    Article  PubMed  Google Scholar 

  21. Zoghbi WA, Adams D, Bonow RO, Enriquez-Sarano M, Foster E, Grayburn PA, et al. Recommendations for noninvasive evaluation of native valvular regurgitation. J Am Soc Echocardiogr. 2017;30(4):303–71.

    Article  PubMed  Google Scholar 

  22. Khoury GE, Glineur D, Rubay J, Verhelst R, d’Acoz d’Udekem Y, Poncelet A, et al. Functional classification of aortic root/valve abnormalities and their correlation with etiologies and surgical procedures. Current Opinion in Cardiology. 2005;20(2):115.

    Article  PubMed  Google Scholar 

  23. le Polain de Waroux JB, Pouleur AC, Goffinet C, Vancraeynest D, Van Dyck M, Robert A, et al. Functional Anatomy of Aortic Regurgitation. Circulation. 2007 Sep 11;116(11_supplement):I–264.

  24. Boodhwani M, de Kerchove L, Glineur D, Poncelet A, Rubay J, Astarci P, et al. Repair-oriented classification of aortic insufficiency: Impact on surgical techniques and clinical outcomes. J Thorac Cardiovasc Surg. 2009;137(2):286–94.

    Article  PubMed  Google Scholar 

  25. Mathari S el, Boulidam N, Heer F de, Kerchove L de, Schäfers HJ, Lansac E, et al. Surgical outcomes of aortic valve repair for specific aortic valve cusp characteristics; retraction, calcification, and fenestration. The Journal of Thoracic and Cardiovascular Surgery. 2023 May 25. https://www.jtcvs.org/article/S0022-5223(23)00444-0/fulltext. Accessed 22 Jun 2023.

  26. Kunihara T. Current controversies in aortic valve-preserving surgery. J Cardiol. 2023;81(2):119–30.

    Article  PubMed  Google Scholar 

  27. Abeln KB, Giebels C, Ehrlich T, Federspiel JM, Schäfers HJ. Which aortic valve can be surgically reconstructed? Curr Cardiol Rep. 2021;23(8):108.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Smer A, Urja P, Anugula D, Dulal S, Elmarzouky ZM, Gill E, et al. Three-dimensional echocardiographic assessment of the aortic valve and the aorta. Echocardiography. 2022;39(7):1011–27.

    Article  PubMed  Google Scholar 

  29. Muraru D, Badano LP, Vannan M, Iliceto S. Assessment of aortic valve complex by three-dimensional echocardiography: a framework for its effective application in clinical practice. Eur Heart Journal Cardiovasc Imaging. 2012;13(7):541–55.

    Article  Google Scholar 

  30. Lancellotti P, Pibarot P, Chambers J, La Canna G, Pepi M, Dulgheru R, et al. Multi-modality imaging assessment of native valvular regurgitation: an EACVI and ESC council of valvular heart disease position paper. Eur Heart J Cardiovasc Imaging. 2022;23(5):e171-232.

    Article  PubMed  Google Scholar 

  31. Perry GJ, Helmcke F, Nanda NC, Byard C, Soto B. Evaluation of aortic insufficiency by Doppler color flow mapping. J Am Coll Cardiol. 1987;9(4):952–9.

    Article  CAS  PubMed  Google Scholar 

  32. Tribouilloy CM, Enriquez-Sarano M, Bailey KR, Seward JB, Tajik AJ. Assessment of severity of aortic regurgitation using the width of the vena contracta: a clinical color Doppler imaging study. Circulation. 2000;102(5):558–64.

    Article  CAS  PubMed  Google Scholar 

  33. Ekery DL, Davidoff R. Aortic regurgitation: quantitative methods by echocardiography. Echocardiography. 2000;17(3):293–302.

    Article  CAS  PubMed  Google Scholar 

  34. Grayburn PA, Handshoe R, Smith MD, Harrison MR, DeMaria AN. Quantitative assessment of the hemodynamic consequences of aortic regurgitation by means of continuous wave Doppler recordings. J Am Coll Cardiol. 1987;10(1):135–41.

    Article  CAS  PubMed  Google Scholar 

  35. Teague SM, Heinsimer JA, Anderson JL, Sublett K, Olson EG, Voyles WF, et al. Quantification of aortic regurgitation utilizing continuous wave Doppler ultrasound. J Am Coll Cardiol. 1986;8(3):592–9.

    Article  CAS  PubMed  Google Scholar 

  36. Labovitz AJ, Ferrara RP, Kern MJ, Bryg RJ, Mrosek DG, Williams GA. Quantitative evaluation of aortic insufficiency by continuous wave Doppler echocardiography. J Am Coll Cardiol. 1986;8(6):1341–7.

    Article  CAS  PubMed  Google Scholar 

  37. Beyer RW, Ramirez M, Josephson MA, Shah PM. Correlation of continuous-wave Doppler assessment of chronic aortic regurgitation with hemodynamics and angiography. Am J Cardiol. 1987;60(10):852–6.

    Article  CAS  PubMed  Google Scholar 

  38. Samstad SO, Hegrenaes L, Skjaerpe T, Hatle L. Half time of the diastolic aortoventricular pressure difference by continuous wave Doppler ultrasound: a measure of the severity of aortic regurgitation? Br Heart J. 1989;61(4):336–43.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  39. de Marchi SF, Windecker S, Aeschbacher BC, Seiler C. Influence of left ventricular relaxation on the pressure half time of aortic regurgitation. Heart. 1999;82(5):607–13.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Griffin BP, Flachskampf FA, Reimold SC, Lee RT, Thomas JD. Relationship of aortic regurgitant velocity slope and pressure half-time to severity of aortic regurgitation under changing haemodynamic conditions. Eur Heart J. 1994;15(5):681–5.

    Article  CAS  PubMed  Google Scholar 

  41. Tribouilloy C, Avinée P, Shen WF, Rey JL, Slama M, Lesbre JP. End diastolic flow velocity just beneath the aortic isthmus assessed by pulsed Doppler echocardiography: a new predictor of the aortic regurgitant fraction. Heart. 1991;65(1):37–40.

    Article  CAS  Google Scholar 

  42. Bolen MA, Popovic ZB, Rajiah P, Gabriel RS, Zurick AO, Lieber ML, et al. Cardiac MR assessment of aortic regurgitation: holodiastolic flow reversal in the descending aorta helps stratify severity. Radiology. 2011;260(1):98–104.

    Article  PubMed  Google Scholar 

  43. Hlubocká Z, Kočková R, Línková H, Pravečková A, Hlubocký J, Dostálová G, et al. Assessment of asymptomatic severe aortic regurgitation by Doppler-derived echo indices: comparison with magnetic resonance quantification. J Clin Med. 2021;11(1):152.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Takenaka K, Dabestani A, Gardin JM, Russell D, Clark S, Allfie A, et al. A simple Doppler echocardiographic method for estimating severity of aortic regurgitation. Am J Cardiol. 1986;57(15):1340–3.

    Article  CAS  PubMed  Google Scholar 

  45. Panaro A, Moral S, Huguet M, Rodríguez Palomares J, Galián L, Gutierrez L, et al. Descending aorta diastolic retrograde flow assessment for aortic regurgitation quantification. Rev Argent Cardiol. 2016;84(4):336–41.

    Article  Google Scholar 

  46. Hasegawa T, Oshima Y, Tanaka T, Maruo A, Matsuhisa H. Clinical assessment of diastolic retrograde flow in the descending aorta for high-flow systemic-to-pulmonary artery shunting. J Thorac Cardiovasc Surg. 2016;151(6):1540–6.

    Article  PubMed  Google Scholar 

  47. Avitabile CM, Whitehead KK, Fogel MA, Kim DW, Kim TS, Rose JD, et al. Holodiastolic flow reversal at the descending aorta on cardiac magnetic resonance is neither sensitive nor specific for significant aortic regurgitation in patients with congenital heart disease. Pediatr Cardiol. 2016;37(7):1284–9.

    Article  PubMed  Google Scholar 

  48. Eren M, Eksik A, Gorgulu S, Norgaz T, Dagdeviren B, Bolca O, et al. Determination of vena contracta and its value in evaluating severity of aortic regurgitation. J Heart Valve Dis. 2002;11(4):567–75.

    PubMed  Google Scholar 

  49. Faber M, Sonne C, Rosner S, Persch H, Reinhard W, Hendrich E, et al. Predicting the need of aortic valve surgery in patients with chronic aortic regurgitation: a comparison between cardiovascular magnetic resonance imaging and transthoracic echocardiography. Int J Cardiovasc Imaging. 2021;37(10):2993–3001.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Tribouilloy CM, Enriquez-Sarano M, Fett SL, Bailey KR, Seward JB, Tajik AJ. Application of the proximal flow convergence method to calculate the effective regurgitant orifice area in aortic regurgitation. J Am Coll Cardiol. 1998;32(4):1032–9.

    Article  CAS  PubMed  Google Scholar 

  51. Pouleur AC, de le Waroux JBP, Goffinet C, Vancraeynest D, Pasquet A, Gerber BL, et al. Accuracy of the flow convergence method for quantification of aortic regurgitation in patients with central versus eccentric jets. Am J Cardiol. 2008;102(4):475–80.

    Article  PubMed  Google Scholar 

  52. Hamirani YS, Dietl CA, Voyles W, Peralta M, Begay D, Raizada V. Acute aortic regurgitation. Circulation. 2012;126(9):1121–6.

    Article  PubMed  Google Scholar 

  53. Botvinick EH, Schiller NB, Wickramasekaran R, Klausner SC, Gertz E. Echocardiographic demonstration of early mitral valve closure in severe aortic insufficiency. Its clinical implications. Circulation. 1975;51(5):836–47.

    Article  CAS  PubMed  Google Scholar 

  54. Chasapi A, Mbonye KA, Bajomo O, Young WJ, Primus C, Ambekar S, et al. Clinical and echocardiographic predictors of decompensation in acute severe aortic regurgitation due to infective endocarditis. Echocardiography. 2021;38(4):590–5.

    Article  PubMed  Google Scholar 

  55. Dahiya A, Bolen M, Grimm RA, Rodriguez LL, Thomas JD, Marwick TH. Development of a consensus document to improve multireader concordance and accuracy of aortic regurgitation severity grading by echocardiography versus cardiac magnetic resonance imaging. Am J Cardiol. 2012;110(5):709–14.

    Article  PubMed  Google Scholar 

  56. Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease. J Am Coll Cardiol. 2021;77(4):e25-197.

    Article  PubMed  Google Scholar 

  57. Wisenbaugh T, Spann JF, Carabello BA. Differences in myocardial performance and load between patients with similar amounts of chronic aortic versus chronic mitral regurgitation. J Am Coll Cardiol. 1984;3(4):916–23.

    Article  CAS  PubMed  Google Scholar 

  58. Gaasch WH, Carroll JD, Levine HJ, Criscitiello MG. Chronic aortic regurgitation: prognostic value of left ventricular end-systolic dimension and end-diastolic radius/thickness ratio. J Am Coll Cardiol. 1983;1(3):775–82.

    Article  CAS  PubMed  Google Scholar 

  59. Tornos MP, Olona M, Permanyer-Miralda G, Herrejon MP, Camprecios M, Evangelista A, et al. Clinical outcome of severe asymptomatic chronic aortic regurgitation: a long-term prospective follow-up study. Am Heart J. 1995;130(2):333–9.

    Article  CAS  PubMed  Google Scholar 

  60. Bonow RO, Dodd JT, Maron BJ, O’Gara PT, White GG, McIntosh CL, et al. Long-term serial changes in left ventricular function and reversal of ventricular dilatation after valve replacement for chronic aortic regurgitation. Circulation. 1988;78(5 Pt 1):1108–20.

    Article  CAS  PubMed  Google Scholar 

  61. Greves J, Rahimtoola SH, McAnulty JH, DeMots H, Clark DG, Greenberg B, et al. Preoperative criteria predictive of late survival following valve replacement for severe aortic regurgitation. Am Heart J. 1981;101(3):300–8.

    Article  CAS  PubMed  Google Scholar 

  62. Wang Y, Jiang W, Liu J, Li G, Liu Y, Hu X, et al. Early surgery versus conventional treatment for asymptomatic severe aortic regurgitation with normal ejection fraction and left ventricular dilatation. Eur J Cardiothorac Surg. 2017;52(1):118–24.

    Article  PubMed  Google Scholar 

  63. Wang Y, Shi J, Li F, Wang Y, Dong N. Aortic valve replacement for severe aortic regurgitation in asymptomatic patients with normal ejection fraction and severe left ventricular dilatation. Interact Cardiovasc Thorac Surg. 2016;22(4):425–30.

    Article  PubMed  Google Scholar 

  64. Kim M, Kim JH, Joo H, Lee S, Youn Y, Lee SH. Prognostic markers and long-term outcomes after aortic valve replacement in patients with chronic aortic regurgitation. J Am Heart Assoc. 2020;9(24): e018292.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Dong N, Jiang W, Yin P, Hu X, Wang Y. Predictors of long-term outcome of isolated surgical aortic valve replacement in aortic regurgitation with reduced left ventricular ejection fraction and extreme left ventricular dilatation. Am J Cardiol. 2020;125(9):1385–90.

    Article  PubMed  Google Scholar 

  66. Zhang Z, Yang J, Yu Y, Huang H, Ye W, Yan W, et al. Preoperative ejection fraction determines early recovery of left ventricular end-diastolic dimension after aortic valve replacement for chronic severe aortic regurgitation. J Surg Res. 2015;196(1):49–55.

    Article  PubMed  Google Scholar 

  67. Yang LT, Anand V, Zambito EI, Pellikka PA, Scott CG, Thapa P, et al. Association of echocardiographic left ventricular end-systolic volume and volume-derived ejection fraction with outcome in asymptomatic chronic aortic regurgitation. JAMA Cardiol. 2021;6(2):189–98.

    Article  PubMed  Google Scholar 

  68. Yang LT, Lee CC, Su CH, Amano M, Nabeshima Y, Kitano T, et al. Analysis of left ventricular indexes and mortality among asian adults with hemodynamically significant chronic aortic regurgitation. JAMA Netw Open. 2023;6(3): e234632.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, et al. ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2021;2021:1–72.

    Google Scholar 

  70. de Meester C, Gerber BL, Vancraeynest D, Pouleur AC, Noirhomme P, Pasquet A, et al. Do Guideline-based indications result in an outcome penalty for patients with severe aortic regurgitation? JACC Cardiovasc Imaging. 2019;12(11 Pt 1):2126–38.

    Article  PubMed  Google Scholar 

  71. Yang LT, Michelena HI, Scott CG, Enriquez-Sarano M, Pislaru SV, Schaff HV, et al. Outcomes in chronic hemodynamically significant aortic regurgitation and limitations of current guidelines. J Am Coll Cardiol. 2019;73(14):1741–52.

    Article  PubMed  Google Scholar 

  72. Park HW, Song JM, Choo SJ, Chung CH, Lee JW, Kim DH, et al. Effect of preoperative ejection fraction, left ventricular systolic dimension and hemoglobin level on survival after aortic valve surgery in patients with severe chronic aortic regurgitation. Am J Cardiol. 2012;109(12):1782–6.

    Article  PubMed  Google Scholar 

  73. Anand V, Yang L, Luis SA, Padang R, Michelena HI, Tsay JL, et al. Association of left ventricular volume in predicting clinical outcomes in patients with aortic regurgitation. J Am Soc Echocardiogr. 2021;34(4):352–9.

    Article  PubMed  Google Scholar 

  74. Yang LT, Enriquez-Sarano M, Michelena HI, Nkomo VT, Scott CG, Bailey KR, et al. Predictors of Progression in patients with stage B aortic regurgitation. J Am Coll Cardiol. 2019;74(20):2480–92.

    Article  PubMed  Google Scholar 

  75. Maeda S, Taniguchi K, Toda K, Funatsu T, Kondoh H, Yokota T, et al. Outcomes after aortic valve replacement for asymptomatic severe aortic regurgitation and normal ejection fraction. Semin Thorac Cardiovasc Surg. 2019;31(4):763–70.

    Article  PubMed  Google Scholar 

  76. Brown ML, Schaff HV, Suri RM, Li Z, Sundt TM, Dearani JA, et al. Indexed left ventricular dimensions best predict survival after aortic valve replacement in patients with aortic valve regurgitation. Ann Thorac Surg. 2009;87(4):1170–5.

    Article  PubMed  Google Scholar 

  77. Cho SH, Byun CS, Kim KW, Chang BC, Yoo KJ, Lee S. Preoperative indexed left ventricular dimensions to predict early recovery of left ventricular function after aortic valve replacement for chronic aortic regurgitation. Circ J. 2010;74(11):2340–5.

    Article  PubMed  Google Scholar 

  78. Zhang MK, Li LN, Xue H, Tang XJ, Sun H, Wu QY. Left ventricle reverse remodeling in chronic aortic regurgitation patients with dilated ventricle after aortic valve replacement. J Cardiothorac Surg. 2022;17(1):8.

    Article  PubMed  PubMed Central  Google Scholar 

  79. Henry WL, Bonow RO, Rosing DR, Epstein SE. Observations on the optimum time for operative intervention for aortic regurgitation. II. Serial echocardiographic evaluation of asymptomatic patients. Circulation. 1980;61(3):484–92.

    Article  CAS  PubMed  Google Scholar 

  80. Kumpuris AG, Quinones MA, Waggoner AD, Kanon DJ, Nelson JG, Miller RR. Importance of preoperative hypertrophy, wall stress and end-systolic dimension as echocardiographic predictors of normalization of left ventricular dilatation after valve replacement in chronic aortic insufficiency. Am J Cardiol. 1982;49(5):1091–100.

    Article  CAS  PubMed  Google Scholar 

  81. Tarasoutchi F, Grinberg M, Spina GS, Sampaio RO, Cardoso L, Rossi FEG, et al. Ten-year clinical laboratory follow-up after application of a symptom-based therapeutic strategy to patients with severe chronic aortic regurgitation of predominant rheumatic etiology. J Am Coll Cardiol. 2003;41(8):1316–24.

    Article  PubMed  Google Scholar 

  82. Sambola A, Tornos P, Ferreira-Gonzalez I, Evangelista A. Prognostic value of preoperative indexed end-systolic left ventricle diameter in the outcome after surgery in patients with chronic aortic regurgitation. Am Heart J. 2008;155(6):1114–20.

    Article  PubMed  Google Scholar 

  83. Saisho H, Arinaga K, Kikusaki S, Hirata Y, Wada K, Kakuma T, et al. Long term results and predictors of left ventricular function recovery after aortic valve replacement for chronic aortic regurgitation. Ann Thorac Cardiovasc Surg. 2015;21(4):388–95.

    Article  PubMed  PubMed Central  Google Scholar 

  84. Bruno P, Cammertoni F, Rosenhek R, Mazza A, Nesta M, Burzotta F, et al. Outcomes of surgery for severe aortic regurgitation with systolic left ventricular dysfunction. J Heart Valve Dis. 2017;26(4):372–9.

    PubMed  Google Scholar 

  85. Koga-Ikuta A, Fukushima S, Kawamoto N, Saito T, Shimahara Y, Yajima S, et al. Reverse remodelling after aortic valve replacement for chronic aortic regurgitation. Interact Cardiovasc Thorac Surg. 2021;33(1):10–8.

    Article  PubMed  PubMed Central  Google Scholar 

  86. Iliuta L, Andronesi AG, Diaconu CC, Moldovan H, Rac-Albu M, Rac-Albu ME. Diastolic versus systolic left ventricular dysfunction as independent predictors for unfavorable postoperative evolution in patients with aortic regurgitation undergoing aortic valve replacement. Medicina. 2022;58(11):1676.

    Article  PubMed  PubMed Central  Google Scholar 

  87. Lang RM, Badano LP, Tsang W, Adams DH, Agricola E, Buck T, et al. EAE/ASE recommendations for image acquisition and display using three-dimensional echocardiography. Eur Heart J Cardiovasc Imaging. 2012;13(1):1–46.

    Article  PubMed  Google Scholar 

  88. Fang L, Hsiung MC, Miller AP, Nanda NC, Yin WH, Young MS, et al. Assessment of aortic regurgitation by live three-dimensional transthoracic echocardiographic measurements of vena contracta area: usefulness and validation. Echocardiography. 2005;22(9):775–81.

    Article  PubMed  Google Scholar 

  89. Sato H, Ohta T, Hiroe K, Okada S, Shimizu K, Murakami R, et al. Severity of aortic regurgitation assessed by area of vena contracta: a clinical two-dimensional and three-dimensional color Doppler imaging study. Cardiovasc Ultrasound. 2015;13(1):24.

    Article  PubMed  PubMed Central  Google Scholar 

  90. Chin CH, Chen CH, Lo HS. The correlation between three-dimensional vena contracta area and aortic regurgitation index in patients with aortic regurgitation. Echocardiography. 2010;27(2):161–6.

    Article  PubMed  Google Scholar 

  91. Perez de Isla L, Zamorano J, Fernandez-Golfin C, Ciocarelli S, Corros C, Sanchez T, et al. 3D color-Doppler echocardiography and chronic aortic regurgitation: a novel approach for severity assessment. Int J Cardiol. 2013;166(3):640–5.

    Article  PubMed  Google Scholar 

  92. Iida N, Seo Y, Ishizu T, Nakajima H, Atsumi A, Yamamoto M, et al. Transmural compensation of myocardial deformation to preserve left ventricular ejection performance in chronic aortic regurgitation. J Am Soc Echocardiogr. 2012;25(6):620–8.

    Article  PubMed  Google Scholar 

  93. Marciniak A, Sutherland GR, Marciniak M, Claus P, Bijnens B, Jahangiri M. Myocardial deformation abnormalities in patients with aortic regurgitation: a strain rate imaging study. Eur J Echocardiogr. 2009;10(1):112–9.

    Article  PubMed  Google Scholar 

  94. Park SH, Yang YA, Kim KY, Park SM, Kim HN, Kim JH, et al. Left ventricular strain as predictor of chronic aortic regurgitation. J Cardiovasc Ultrasound. 2015;23(2):78–85.

    Article  PubMed  PubMed Central  Google Scholar 

  95. Olsen NT, Sogaard P, Larsson HBW, Goetze JP, Jons C, Mogelvang R, et al. Speckle-tracking echocardiography for predicting outcome in chronic aortic regurgitation during conservative management and after surgery. JACC Cardiovasc Imaging. 2011;4(3):223–30.

    Article  PubMed  Google Scholar 

  96. Alashi A, Mentias A, Abdallah A, Feng K, Gillinov AM, Rodriguez LL, et al. Incremental prognostic utility of left ventricular global longitudinal strain in asymptomatic patients with significant chronic aortic regurgitation and preserved left ventricular ejection fraction. JACC Cardiovasc Imaging. 2018;11(5):673–82.

    Article  PubMed  Google Scholar 

  97. Lavine SJ, Al Balbissi KA. Reduced longitudinal function in chronic aortic regurgitation. J Cardiovasc Ultrasound. 2015;23(4):219–27.

    Article  PubMed  PubMed Central  Google Scholar 

  98. deCampos D, Teixeira R, Saleiro C, Botelho A, Gonçalve L. Global longitudinal strain in chronic asymptomatic aortic regurgitation: systematic review. Echo Res Pract. 2020;7(3):39–48.

    Article  PubMed  PubMed Central  Google Scholar 

  99. Alashi A, Khullar T, Mentias A, Gillinov AM, Roselli EE, Svensson LG, et al. Long-term outcomes after aortic valve surgery in patients with asymptomatic chronic aortic regurgitation and preserved LVEF: impact of baseline and follow-up global longitudinal strain. JACC Cardiovasc Imaging. 2020;13(1, Part 1):12–21.

    Article  PubMed  Google Scholar 

  100. Jenner J, Ilami A, Petrini J, Eriksson P, Franco-Cereceda A, Eriksson MJ, et al. Pre- and postoperative left atrial and ventricular volumetric and deformation analyses in severe aortic regurgitation. Cardiovasc Ultrasound. 2021;19(1):14.

    Article  PubMed  PubMed Central  Google Scholar 

  101. Kalkan S, Efe SC, Tasar O, Koyuncu A, Yilmaz FM, Batgerel U, et al. The role of the left atrial strain parameters on grading of aortic regurgitation. J Cardiovasc Echogr. 2021;31(3):151–6.

    PubMed  PubMed Central  Google Scholar 

  102. García Martín A, Abellás Sequeiros M, González Gómez AG, Rincón Díaz LM, Monteagudo Ruiz JM, Hinojar Baydés R, et al. Prognostic value of diastolic function parameters in significant aortic regurgitation: the role of the left atrial strain. J Echocardiogr. 2022;20(4):216–23.

    Article  PubMed  Google Scholar 

  103. Hulshof HG, van Dijk AP, George KP, Hopman MTE, Thijssen DHJ, Oxborough DL. Exploratory assessment of left ventricular strain–volume loops in severe aortic valve diseases. J Physiol. 2017;595(12):3961–71.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  104. Mizarienė V, Bučytė S, Zaliaduonytė-Pekšienė D, Jonkaitienė R, Janėnaitė J, Vaškelytė J, et al. Components of left ventricular ejection and filling in patients with aortic regurgitation assessed by speckle-tracking echocardiography. Medicina. 2012;48(1):31–8.

    Article  PubMed  Google Scholar 

  105. Ewe SH, Haeck MLA, Ng ACT, Witkowski TG, Auger D, Leong DP, et al. Detection of subtle left ventricular systolic dysfunction in patients with significant aortic regurgitation and preserved left ventricular ejection fraction: speckle tracking echocardiographic analysis. Eur Heart J Cardiovasc Imaging. 2015;16(9):992–9.

    PubMed  Google Scholar 

  106. Verseckaite R, Mizariene V, Montvilaite A, Auguste I, Bieseviciene M, Laukaitiene J, et al. The predictive value of left ventricular myocardium mechanics evaluation in asymptomatic patients with aortic regurgitation and preserved left ventricular ejection fraction. A long-term speckle-tracking echocardiographic study. Echocardiography. 2018;35(9):1277–88.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

No funding was obtained for this review.

Author information

Authors and Affiliations

  1. Norwich Medical School, University of East Anglia, Norwich, NR4 7TJ, UK

    Vasiliki Tsampasian

  2. Cleveland Clinic London, London, UK

    Kelly Victor

  3. St Bartholomew’s Hospital, Barts’ Heart Centre, London, UK

    Sanjeev Bhattacharyya

  4. Research Institute of Sports and Exercise Science and Liverpool Centre for Cardiovascular Science, Liverpool John Moores University, Liverpool, UK

    David Oxborough

  5. West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, UK

    Liam Ring

Authors
  1. Vasiliki Tsampasian
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Kelly Victor
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Sanjeev Bhattacharyya
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. David Oxborough
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Liam Ring
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

VT performed the literature review and drafted the first manuscript. KV critically evaluated and amended the manuscript. SB critically evaluated and amended the manuscript. DO critically evaluated and amended the manuscript. LR critically evaluated and amended the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Vasiliki Tsampasian.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

KV and DO are Editorial Board Members of the Echo Research & Practice Journal. This has not influenced their participation or any parts of the submitted manuscript.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Tsampasian, V., Victor, K., Bhattacharyya, S. et al. Echocardiographic assessment of aortic regurgitation: a narrative review. Echo Res Pract 11, 1 (2024). https://doi.org/10.1186/s44156-023-00036-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s44156-023-00036-7

Keywords

Echo Research & Practice

ISSN: 2055-0464

Contact us