Presentation depends on whether the valvular insufficiency is an acute or a chronic process.

Patients with acute aortic insufficiency have severe dyspnea, signs of cardiogenic shock (tachycardia, hypotension), cyanosis, pulmonary edema, acute heart failure (fatigability and peripheral edema) and chest pain if coronary or aortic dissection is the cause of the regurgitation [1].

Chronic aortic insufficiency leads to palpitations and dyspnea which is initially exertional and afterward occurs with minimal efforts and chest pain if coronary perfusion is compromised. As the disease progresses, orthopnea and paroxysmal nocturnal dyspnea start to occur. Angina is predominantly nocturnal in these patients. As with all valvular diseases, aortic insufficiency is prone to endocarditis, manifesting as fever and central or peripheral embolism.

Auscultation reveals single S1 and S2 sounds and a diastolic descrescendo, high-pitched murmur that increases with squatting. Systolic blood pressure tends to increase, while the diastolic component is prone to decrease.

Chronic aortic insufficiency, but not the acute form, is accompanied by several peripheral signs, reflecting increased stroke volume and wide pulse pressure: pulsation of the liver (Rosenbach), spleen (Gerhardt), retinal arterioles (Becker), cervix (Shelly), uvula (De Musset), capillaries of the nail bed (Quincke), systolic contraction and diastolic dilation of the pupil (Landolfi). In aortic insufficiency, auscultation of the femoral artery reveals systolic and diastolic sounds (Traube) and bruits if the artery is slightly compressed (Duroziez). The "water-hammer" pulse is known as Corrigan's sign, while De Musset's sign describes a specific bobbing motion of the head with each cardiac cycle. When popliteal blood pressure is at least 60 mm Hg higher than the brachial one, Hill's sign is present and if diastolic brachial pressure decreases by at least 15 mm Hg when the arm is raised above the head, Mayne's sign should be noticed. As symptoms worsen, so does the prognosis [2].

• Fatigue

  See your doctor if you have fatigue, shortness of breath, and swollen ankles and feet, which are common symptoms of heart failure. Causes Your heart has four valves that keep blood flowing in the correct direction. [mayoclinic.org]

  Other symptoms may include fatigue, shortness of breath, or heavy or rapid breathing, especially during exercise. [uwhealth.org]

  Symptoms can include fatigue, fainting, shortness of breath, palpitations (sensation of the heart beating), and swelling of the feet, legs, or abdomen. [uabmedicine.org]

  If your heart isn't working efficiently, you may feel aortic regurgitation symptoms including fatigue and short of breath. Aortic regurgitation can develop suddenly or over decades. It has a variety of causes, such as rheumatic fever or infection. [heart-valve-surgery.com]

• Congestive Heart Failure

  The left ventricle may begin to enlarge and dilate, which can lead to congestive heart failure. Some patients may also develop an abnormal heartbeat (arrhythmia). [uwhealth.org]

  The main one is congestive heart failure. Medicines may not be effective in treating tricuspid regurgitation. Diuretics, or water pills, can help relieve body swelling, or edema, that’s due to congestive heart failure. [webmd.com]

  When the heart cannot pump enough oxygenated blood to the body, congestive heart failure occurs. [jrcinsurancegroup.com]

  In chronic severe aortic regurgitation the apex may be displaced to the left on posterior-anterior projections, and there may be signs of congestive heart failure 1. [radiopaedia.org]

• Weakness

  However symptoms may include Tiredness Weakness Shortness of breath, especially with exercise or when you lie down Lightheadedness or fainting Swollen ankles ( oedema ) Treatment If the backflow of blood is mild then you may not need any treatment. [patient.info]

  […] increases with exercise and goes away with rest Fainting Fatigue Palpitations (sensation of the heart beating) Shortness of breath with activity or when lying down Swelling of the feet, legs or abdomen Uneven, rapid, racing, pounding or fluttering pulse Weakness [wexnermedical.osu.edu]

• Chest Discomfort

  A 58-year-old man who underwent AVR with mechanical valve due to severe aortic regurgitation secondary to BAV 7 years previously presented with exertional chest discomfort for 1 year. [ncbi.nlm.nih.gov]

  He presented to the local clinic with increasing of shortness of breath on exertion in the last 6 months and occasionally chest discomfort. Past medical history was unremarkable. [clinicsinsurgery.com]

  discomfort Dyspnea Hypotension Uncomfortable awareness of heartbeat/palpitations Chest pain Sudden cardiovascular collapse Cause of symptoms in acute severe aortic valve insufficiency Sudden drop in coronary driving pressure Increased filling pressure [emedicine.medscape.com]

  discomfort Shortness of breath Lightheadedness Dizziness Fainting Visit our Aortic Stenosis page to learn more. [umcvc.org]

• Impaired Exercise Tolerance

  In addition, physicians may have a lower threshold for referring a patient for AVR after a treadmill test in which the patient had impaired exercise tolerance, presumed symptoms, or an abnormal blood pressure response compared with patients with excellent [content.onlinejacc.org]

• Dyspnea

  As the disease progresses, orthopnea and paroxysmal nocturnal dyspnea start to occur. Angina is predominantly nocturnal in these patients. [symptoma.com]

  Specialty Cardiology Symptoms Dyspnea on exertion, Orthopnea Hamirani, Yasmin S.; Dietl, Charles A.; Voyles, Wyatt; Peralta, Mel; Begay, Darlene; Raizada, Veena (2012-08-28). "Acute Aortic Regurgitation". [en.wikipedia.org]

  Chronic AR is typically asymptomatic for years followed by progressive exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. [msdmanuals.com]

  (common) Orthopnea (common) Paroxysmal nocturnal dyspnea (common) Angina pectoris (less common) Abdominal discomfort (less common) Syncope (rare) Nocturnal angina with diaphoresis (rare) Causes of symptoms in chronic severe aortic valve insufficiency [emedicine.medscape.com]

  Over time, heart failure symptoms manifest: exertional dyspnea, orthopnea and paroxysmal nocturnal dyspnea. Eventually, patients experience dyspnea at rest, reflecting severe decompensated heart failure. [clinicaladvisor.com]

• Orthopnea

  Specialty Cardiology Symptoms Dyspnea on exertion, Orthopnea Hamirani, Yasmin S.; Dietl, Charles A.; Voyles, Wyatt; Peralta, Mel; Begay, Darlene; Raizada, Veena (2012-08-28). "Acute Aortic Regurgitation". [en.wikipedia.org]

  As the disease progresses, orthopnea and paroxysmal nocturnal dyspnea start to occur. Angina is predominantly nocturnal in these patients. [symptoma.com]

  Chronic AR is typically asymptomatic for years followed by progressive exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. [msdmanuals.com]

  Signs of acute left heart failure — including severe dyspnea, even at rest, orthopnea and PND — arise. Hypotension, flash pulmonary edema and shock can also occur. [healio.com]

• Exertional Dyspnea

  Chronic AR is typically asymptomatic for years followed by progressive exertional dyspnea, orthopnea, and paroxysmal nocturnal dyspnea. [msdmanuals.com]

  […] the ascending aorta Catheter balloon valvuloplasty Trauma Chronic : Etiology Rheumatic fever Marfan's syndrome Hypertension Bicuspid aortic valve Membranous ventricular septal defect Ascending aortic aneurysm Aortic valve prolapse Signs and Symptoms Exertional [echocardiology.org]

  […] the left ventricle (LV) and gradual increase of stroke volume in most cases No symptoms for many years in most patients with chronic aortic valve insufficiency No symptoms for decades in most patients with chronic moderate aortic valve insufficiency Exertional [emedicine.medscape.com]

  Case presentation Case 1 A 58-year-old Chinese man was admitted to our department with chief complaint of exertional dyspnea for one month. His past medical history was unremarkable. [cardiothoracicsurgery.biomedcentral.com]

  Hence, in some patients determined to have only moderate MS at rest, the physiologic effects of heart rate sensitivity and atrioventricular compliance can produce exercise-induced pulmonary hypertension and exertional dyspnea. [content.onlinejacc.org]

• Abdominal Pain

  Hepatic congestion can also occur, producing right upper quadrant abdominal pain. Palpitations may result from the large stroke volumes and forceful LV contractions. [healio.com]

• Pulsatile Liver

  liver) Gerhardt's sign (enlarged spleen) Duroziez's sign (systolic and diastolic murmurs heard over the femoral artery when it is gradually compressed) Hill's sign (A 20 mmHg difference in popliteal and brachial systolic cuff pressures, seen in chronic [doctorslounge.com]

• Heart Disease

  Aortic valve insufficiency can be due to, or associated with, congenital heart disease. [emedicine.medscape.com]

  A young woman with aortic valve insufficiency secondary to rheumatic heart disease underwent replacement of her diseased aortic valve with her own pulmonary valve and replacement of her pulmonary valve with an aortic cadaver homograft, the Ross procedure [ncbi.nlm.nih.gov]

  Stenosis - when the valve doesn't open enough and blocks blood flow Valve problems can be present at birth or caused by infections, heart attacks, or heart disease or damage. [icdlist.com]

• Hypertension

  It is accompanied by systolic hypertension and wide pulse pressure, which account for peripheral physical findings, such as bounding pulses. [ncbi.nlm.nih.gov]

  Moderate or severe tricuspid regurgitation may result from pulmonary hypertension. Pulmonary hypertension is high blood pressure in the pulmonary artery. This high blood pressure has many possible causes. The main one is congestive heart failure. [webmd.com]

  Surgery is also reasonable (Class IIa) for patients who have pulmonary hypertension at rest or new-onset atrial fibrillation if they are candidates for mitral valve (MV) repair. [content.onlinejacc.org]

  Occasionally aortic insufficiency may be a result of bacterial endocarditis, dilatation of the aortic valve ring, hypertension and aortic arteriosclerosis, dissecting aortic aneurysm or trauma. [annals.org]

• Chest Pain

  Chronic aortic insufficiency leads to palpitations and dyspnea which is initially exertional and afterward occurs with minimal efforts and chest pain if coronary perfusion is compromised. [symptoma.com]

  Progressive expansion of the aneurysm may result in both aortic dissection or rupture with fatal hemorrhage and increasing aortic valvular regurgitation.1 Effective surgical therapy would relieve cardiac failure and chest pain due to valvular incompetence [jamanetwork.com]

  Symptoms may include chest pain or pressure, fainting, and shortness of breath. These are signs that you are likely to need surgery. [northshore.org]

  You have aortic insufficiency and your symptoms worsen or new symptoms develop (especially chest pain, difficulty breathing, or swelling ). Blood pressure control is very important if you are at risk for aortic regurgitation. [nlm.nih.gov]

• Palpitations

  Symptoms can include fatigue, fainting, shortness of breath, palpitations (sensation of the heart beating), and swelling of the feet, legs, or abdomen. [uabmedicine.org]

  People with more severe aortic regurgitation may notice heart palpitations, chest pain, fatigue, or shortness of breath. Other symptoms include difficulty breathing when lying down, weakness, fainting, or swollen ankles and feet. [heart.org]

  Chronic aortic insufficiency leads to palpitations and dyspnea which is initially exertional and afterward occurs with minimal efforts and chest pain if coronary perfusion is compromised. [symptoma.com]

  […] history of aortic insufficiency High blood pressure Use of drugs such as weight loss and appetite suppressant medications Symptoms of aortic insufficiency include: Shortness of breath with activity Exercise intolerance Lightheadedness Chest pain Heart palpitations [health.cvs.com]

• Heart Murmur

  The main sign of heart valve disease is an unusual heartbeat sound called a heart murmur. Your doctor can hear a heart murmur with a stethoscope. But many people have heart murmurs without having a problem. [icdlist.com]

  At CHOP's Cardiac Center, we usually diagnose aortic regurgitation after a primary care doctor detects a heart murmur and refers a child to us. [chop.edu]

  Physical examination Echocardiography The diagnosis is based on the results of a physical examination (such as the collapsing pulse and characteristic heart murmur) and confirmed by echocardiography. [merckmanuals.com]

  This video on aortic insufficiency (regurgitation) is part of a series on heart murmurs and valves called "Heart Valves Explained Clearly." [youtube.com]

Blood workup in aortic valve insufficiency should include complete blood count, inflammatory markers, and cultures if endocarditis is suspected, coagulation parameters like prothrombin time and activated partial thromboplastin time, electrolyte panel, renal and hepatic tests and lactate dehydrogenase.

Echocardiography is a valuable and accurate tool in aortic insufficiency, allowing morphological valvular description, vegetation identification, and ascending aorta evaluation for dissection or aneurysm. Cavity dimensions and ejection fraction should be evaluated, especially if surgical intervention is needed [3].

Severe aortic valvular insufficiency is defined by certain parameters, derived from color, continuous and pulsed wave Doppler studies: vena contracta > 6 mm, regurgitant volume > 60 mL/beat, regurgitation fraction > 50%, and holodiastolic flow reversal in the descending aorta. Left ventricle dilation and ejection fraction should also be investigated, as well as pulmonary hypertension, pericardial effusion and aortic dissection [4]. Transesophageal echocardiography is especially useful in patients with poor acoustic windows or valvular calcification which makes it difficult to identify valve anatomy. An enlarged aorta may need additional characterization using computer tomography [5] or magnetic resonance imaging [6], while radionuclide imaging may be useful in further investigating left ventricular ejection fraction if echocardiography results are disproportional to clinical status.

Electrocardiography can show cavity enlargement or hypertrophy or ischemia, while chest radiography shows cardiac dilatation with valvular insufficiency is chronic and a cardiac normal size if the problem is acute in character. In addition, X-ray helps to detect pulmonary edema.

Exercise testing is indicated in order to assess functional capacity of the heart in chronic aortic regurgitation [7].

Aortic angiography is indicated if dissection is suspected while coronary angiography is performed in all patients scheduled to undergo aortic valvular replacement, in order to assess the need for a concomitant coronary bypass [8].

• Left Axis Deviation

  axis deviation（英语：Left axis deviation） QT（英语：QT interval） Short QT syndrome（英语：Short QT syndrome） T T wave alternans（英语：T wave alternans） ST Osborn wave（英语：Osborn wave） ST elevation（英语：ST elevation） ST depression（英语：ST depression） Strain pattern（英语：Strain [zh.wikipedia.org]

1. Babu AN, Kymes SM, Carpenter Fryer SM. Eponyms and the diagnosis of aortic regurgitation: what says the evidence?. Ann Intern Med. 2003;138(9):736-742.
2. Dujardin KS, Enriquez-Sarano M, Schaff HV, et al. Mortality and morbidity of aortic regurgitation in clinical practice. A long-term follow-up study. Circulation 1999;99:1851 – 1857.
3. Friedman T, Mani A, Elefteriades JA. Bicuspid aortic valve: clinical approach and scientific review of a common clinical entity. Expert Rev Cardiovasc Ther. 2008;6(2):235-248.
4. Lancellotti P, Tribouilloy C, Hagendorff A, et al. European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease). Eur J Echocardiogr. 2010;11(3):223-244.
5. Gaztanaga J, Pizarro G, Sanz J. Evaluation of cardiac valves using multidetector CT. Cardiol Clin. 2009;27(4):633-644.
6. Morello A, Gelfand EV. Cardiovascular magnetic resonance imaging for valvular heart disease. Curr Heart Fail Rep. 2009;6(3):160-166
7. Picano E, Pibarot P, Lancellotti P. The emerging role of exercise testing and stress echocardiography in valvular heart disease. J Am Coll Cardiol. 2009;54(24):2251-2260.
8. [Guideline] Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129 (23):e521-643.