Also known as valvular incompetence or valvular insufficiency, valvular regurgitation is a condition in which blood leaks in the wrong direction because one or more of the heart’s valves is closing improperly. Valvular regurgitation may occur in any of the four valves of the heart: the aortic valve, the mitral valve, the tricuspid valve or the pulmonic valve.

In a normal heart, these valves allow blood to flow in only one direction and only at the right time during a heartbeat. Mild valvular regurgitation may not show any symptoms, but it could lead to more serious problems, such as heart failure, as the leak worsens. Therefore, regular physical checkups with one’s physician are very important. It is also important to report any unusual symptoms (e.g., fatigue, shortness of breath because these may be signs of more severe valvular regurgitation.

For women, mitral regurgitation due to mitral valve prolapse does not typically cause any problems during pregnancy. However, impairment of the heart’s left ventricle (left ventricular dysfunction) with mitral regurgitation increases maternal risks during pregnancy. Similarly, women with aortic valve regurgitation who do not have symptoms may have no cardiac health problems associated with pregnancy. Women with symptoms, however, may need to have their condition treated before becoming pregnant.

According to the American Heart Association's 2006 Heart and Stroke Statistical Update, valvular heart disease is responsible for more than 19,700 deaths each year in the United States and is a contributing factor in about 42,000 deaths. The majority of these cases involve disorders of the aortic valve (more than 50 percent) and the mitral valve. Deaths due to pulmonic and tricuspid valve disorders are much more rare.

People who have valvular regurgitation will need to take antibiotics before undergoing most types of medical procedures or surgeries, and all dental procedures – even a check-up or cleaning. Other treatments for valvular regurgitation may include medications such as ACE inhibitors, inotropes, diuretics and surgeries such as a heart valve repair or replacement.

In a normal heart, the flow of blood between the atria and ventricles (upper and lower chambers), and blood flow out of the heart, is regulated by four valves. These valves are made from thin flaps of tissue. They only open one way, and only at the right time, to keep blood flowing in the right direction.

In some cases, however, a valve may be diseased or otherwise unable to function normally. This may result in blood flowing backward (e.g. from the left ventricle to the left atrium). This condition is known as valvular regurgitation, or alternatively, as valvular incompetence or valvular insufficiency. Valvular regurgitation may occur in any of the four valves of the heart: the aortic valve, the mitral valve, the tricuspid valve or the pulmonic valve. Depending on the severity of the leak, there can be as much as two drops of blood that leak backward for every three drops of blood that travel forward.

Valvular regurgitation may prevent the heart from circulating enough blood to the lungs or tissues and organs of the body. To compensate, the left and right ventricles (pumping chambers of the heart) must work harder. As a result, one or both ventricles may eventually be damaged from the increased workload. This damage may be accompanied by myocardial (heart muscle) dilation and hypertrophy (thickening and enlargement of the heart). In the most severe cases, valvular regurgitation could lead to heart failure, a condition in which the heart cannot pump enough blood to satisfy the body, and the  lungs become congested with fluid and/or the legs become swollen (edema).

Valvular heart disease may be either congenital (developed before birth) or acquired as a result of conditions such as:

Researchers are continually exploring other possible causes of valvular regurgitation. Radiation cancer therapy, for example, often increases the risk of medical complications secondary to the disease itself, particularly when used in combination with some chemotherapy drugs. Depending on the location of the tumor, radiation may be directed to the underarms, neck and chest. This is known as mantle field radiation. Inverted Y radiation is used for the abdomen, spleen, pelvis or groin. With mantle field radiation – especially at high doses – there is potentially latent damage to the throat, lungs, thyroid and heart. Areas of the heart that may be affected include:

• Pericardium (outer tissue layer)
• Myocardium (heart muscle itself)
• valves and arteries
• Blood vessels leading to the heart

It is important, therefore, to have regular follow-up examinations with physicians knowledgeable about the effects of chemotherapy and radiotherapy on a particular area of the body. Ongoing research has included testing of newer types of radiation therapy, with the ability to “mold” its beam according to the shape and size of the tumor. This would greatly minimize its impact on surrounding tissues and organs and, therefore, the risk of long-term problems.

In a normally functioning heart, each of the four valves has its own set of “gates” or tissue flaps that swing open to let blood flow from one area to the next. Between contractions, the flaps should neatly close again until the next cycle begins. Thus, blood should flow only in one direction and only at the right time. The routes traveled by oxygen-rich and oxygen-poor blood are:

There are four different types of valvular regurgitation, which correspond to the four types of heart valves: aortic regurgitation, mitral regurgitation, tricuspid regurgitation and pulmonary regurgitation.

Aortic regurgitation is a condition in which the aortic valve does not close tightly. Because the defective aortic valve is located between the left ventricle and the aorta, this abnormality allows blood to leak back into the left ventricle instead of going into the aorta and out to the rest of the body. As a result, the body receives less oxygen-rich blood and the left ventricle is stretched (dilated) from the extra blood that pours back into it. Furthermore, the pulse tends to be faster and the systolic blood pressure in the aorta tends to be higher.

There are two forms of aortic regurgitation: acute and chronic. Acute aortic regurgitation is often a medical emergency. Pumping function, blood flow and blood pressure may be suddenly and significantly lessened, usually due to infective endocarditis. It can also be caused by aortic dissection, blunt trauma and surgical errors. Patients with this condition frequently go into shock because the left ventricle cannot rapidly adjust to the sudden rise in blood pressure. Treatment is usually an emergency aortic valve replacement.

Chronic aortic regurgitation develops over a period of years (with or without symptoms). Although the heart initially adapts well to the condition, it may eventually lead to heart failure due to the long period of time during which the ventricles were overworked. Chronic aortic regurgitation is due to scarring from past diseases such as rheumatic fever (now rare in the United States) or endocarditis (an inflammation of the heart lining most often caused by a bacterial infection). The scarring left by these conditions on the heart can affect the function and form of the valves. 

Other conditions that can contribute to the development of chronic aortic regurgitation include:

Mitral regurgitation, which affects about two percent of the U.S. population, is a condition in which the mitral valve, located between the left atrium and the left ventricle, is defective. As a result, the defective mitral valve allows blood to leak back into the left atrium instead of continuing forward into the left ventricle. The extra blood pours back into the left atrium and can lead to lung congestion. The condition can persist for years without detection, as the heart overworks to compensate for the valvular shortcomings. Eventually, overall cardiac efficiency is reduced. Untreated, the left ventricle muscle can eventually thicken until it fails altogether (heart failure).

Mitral regurgitation can be caused by:

• Mitral valve prolapse. This is a condition in which the leaflets of the mitral valve do not close properly. It is the most common cause of mitral valve regurgitation. The condition is sometimes also caused degenerative or myxomatous mitral valve disease.
  
  
• Myxomatous degeneration of the mitral leaflets. A weakening of valve tissue resulting in a loss of tissue elasticity and strength.
  
  
• Dilated, failing left ventricle in which the papillary muscles and chordae supporting the mitral valve fail to allow the valve to close properly.
  
  
• Repeated episodes of cardiac ischemia (in which the heart does not get enough oxygen-rich blood).
  
  
• Scarring due to rheumatic fever or endocarditis.
  
  
• Rupture of the chordae fastening the valve to the chamber wall, sometimes caused by trauma.
  
  
• Congential heart defects.

Tricuspid regurgitation is a condition in which the tricuspid valve (located between the right atrium and the right ventricle) does not close properly. As a result, blood leaks back into the right atrium. A small degree of tricuspid regurgitation occurs in a majority of healthy adults and is not a concern. However, more serious tricuspid regurgitation can be caused by underlying conditions, such as heart failure, lung disorders such as pulmonary embolism or pulmonary hypertension, and thyroid disorders. It can also be caused by valvular abnormalities, such as those caused by prolapse, injury from a pacemaker, endocarditis and rheumatic fever.

Only about 10 percent of the cases of patients with endocarditis involve the tricuspid valve, but this number increases to 50 percent among people who also use intravenous drugs. Because the right ventricle tolerates tricuspid insufficiency relatively well, treatment is aimed at that underlying disease.

Pulmonary regurgitation is a condition in which the pulmonic valve (located between the right ventricle and the pulmonary artery does not close properly. As a result, blood leaks back into the right ventricle instead of traveling through the pulmonary artery to the lungs. Depending on how severe this condition is, as well as its cause (e.g., Congenital heart defects that lead to high pulmonary artery pressures), signs such as cyanosis (a bluish tint to the skin) could result from not enough blood getting to the lungs to absorb oxygen.

Like other types of valvular heart disease, valvular regurgitation may go unnoticed for years because mild forms tend to produce no symptoms. Symptoms are related to the severity of the regurgitation, as well as the presence of other forms of heart disease.  More severe forms may cause symptoms such as:

While the symptoms listed above are the problems that patients may bring to their physician’s attention, valvular regurgitation may also produce a number of signs that only the physician will be able to find. These signs include:

• Heart murmur, an abnormal heart sound that is detected by a physician through a stethoscope
  
  
• Arrhythmias (abnormal heart rhythms), including atrial fibrillation
  
  
• Lung congestion
  
  
• Blood clots

Diagnosing valvular regurgitation begins with the physician obtaining the patient’s full medical history and giving the patient a physical examination. As part of the physical examination, the physician will listen to the patient’s heart through a stethoscope. The physician will also listen to the patient’s pulse. Certain murmurs and telltale pulse motion characteristics, such as the “water hammer” pulse, can help physicians determine whether a valve defect is present and, if so, pinpoint its cause and severity.

The next diagnostic step will be an electrocardiogram (EKG). This is a recording of the heart’s electrical activity as a graph on a moving strip of paper or video monitor. The highly sensitive electrocardiograph machine helps detect heart irregularities, disease and damage by measuring the heart’s rhythms and electrical impulses. This test can indicate if any of the heart’s chambers are enlarged (the left ventricle in particular) and if arrhythmias are occurring.

If the patient’s history, physical examination and EKG suggest the presence of valvular regurgitation, then additional tests will be ordered. Noninvasive tests include:

• Chest x-ray. A radiation-based imaging test that offers the physician a picture of the general size, shape, and structure of the heart and lungs. An enlarged heart can indicate damage or dysfunction.

If these noninvasive tests do not offer enough information, then an invasive procedure called a cardiac catheterization may need to be done. During the cardiac catheterization, pressure measurements will be taken within the heart using catheters to determine the severity of the leakage, and a coronary angiogram may be done to ensure the coronary anatomy is normal. To perform the angiogram, the physician injects a special dye (contrast medium) into the coronary arteries. To do this, the physician inserts a thin tube (catheter) through a blood vessel, usually in the upper thigh, and up into the origin of the coronary arteries. Once the catheter is in place, the physician can inject the dye through the catheter and into the coronary arteries. Then the x-ray can be taken. Following the coronary angiogram, a left ventricular angiogram will be performed. An aortogram may also be done to assess aortic regurgitation.

The specific course of treatment depends upon the nature and severity of the valve disease. Some conditions, such as mitral prolapse valve with mild mitral regurgitation, often require little treatment except for taking antibiotics before dental, medical or surgical procedures. More severe valve abnormalities may require cardiac medications and/or valve surgery. Regardless of the nature and severity of the valve defect, early detection and diagnosis can increase a patient’s chances of avoiding significant and sometimes irreversible damage.

Drugs will not cure the underlying disease, but they can minimize symptoms, ease the heart’s workload, and regulate the heart’s rhythm to prevent arrhythmias and delay the need for surgery. Medications include:

Surgeries include:

• Heart valve repair or replacement. Using a valve transplant made of artificial materials (e.g., plastics, carbon, metal alloys) or organic tissue (from pig or cow), defective valves are replaced with healthy ones. This is an open-heart surgery that requires the use of a heart-lung machine. Patients who have received a mechanical valve are at an increased risk of blood clot formation and must take anticoagulants for the rest of their lives.
  
  
• Certain minimally invasive heart valve surgeries. Researchers are working to develop a catheter-based valve replacement surgery.
  
  
• Valvuloplasty. A procedure in which a ring-like device is attached to the supporting structures of the valve as the valve’s (usually the mitral valve) leaflets or “flaps” are re-molded to prevent leakage.
  
  
• Other surgical repair of valve(s). These surgeries include the Ross Procedure in which the patient's pulmonic valve is moved to the aortic valve position, with the pulmonic valve being replaced with a pig valve.

Preparing questions in advance can help patients have more meaningful discussions with their physicians about their conditions. Patients may wish to ask their doctors the following questions related to valvular regurgitation:

1. How can I tell if I have a valvular regurgitation?
   
   
2. Is there any way to tell which of my heart valves is affected? What is the difference?
   
   
3. What sorts of conditions or events does a valvular regurgitation put me at risk for?
   
   
4. Do I have any risk factors that put me at increased risk of valvular regurgitation?
   
   
5. How much danger does valvular regurgitation put me in?
   
   
6. Are there any lifestyle changes I can make to reduce the chance that valvular regurgitation will occur?
   
   
7. Do you recommend any medications, therapies or surgeries to fix the valvular regurgitation?
   
   
8. Are there any activities that I should avoid?
   
   
9. Will I need to have a valve replaced?
   
   
10. Do I need to have valvular regurgitation treated before I become pregnant?