• echocardiography
• cardiac magnetic resonance (cmr) imaging
• valve disease surgery
• heart failure with reduced ejection fraction
• aortic regurgitation

Chronic aortic regurgitation (AR) is associated with increased preload (regurgitant volume overload) and afterload (increased end-diastolic volume and wall stress), leading to left ventricular (LV) dilatation and systolic impairment that precede the onset of symptoms. Progression is slow—surgery is required in <4% of asymptomatic patients with normal LV dimensions per annum,1 yet risk of mortality rises to 10%–20% per annum once symptoms surface.

Chronic AR may result from root enlargement (for example, from hypertension or Marfan syndrome) or gradual disruption of the normal valve leaflets secondary to congenital aortic valve abnormalities, rheumatic fever, collagen vascular disease, infective endocarditis or atherosclerotic degeneration. AR may be classified into three subtypes2: type 1 where annuloaortic ectasia leads to failure of coaptation and central AR, type 2 where cusp prolapse or fenestration leads to eccentric AR and type 3 where cusp retraction with poor tissue quality results in central or eccentric AR. Comprehensive echocardiography is the mainstay of evaluation and surveillance allowing assessment of aetiology, severity and haemodynamic effects on the LV. Severe AR is defined by the integration of numerous echocardiographic parameters: regurgitant volume ≥60 mL/beat, regurgitant fraction ≥50% and an orifice area ≥0.3 cm², jet width: LV outflow tract diameter ≥65%, pressure half time <200 ms and vena contracta width >0.6 cm. In patients where echocardiography is challenging or equivocal (or LV function is borderline), cardiac magnetic resonance (CMR) imaging is of value and can also provide additional detail concerning concomitant aortic pathology. Nevertheless, the prediction of symptom onset and LV decompensation remains difficult and careful surveillance is recommended in specialist valve clinics.3

The importance of AR has been overlooked in the furore of interest surrounding aortic stenosis since the advent of percutaneous valve intervention. Only one in six surgical …