Aortic regurgitation:
when monitoring is enough and when intervention is needed

Article written and reviewed by Dr Luca Moretti

Mild or moderate aortic regurgitation, in the absence of other cardiac indications, is often monitored over time. When the regurgitation is severe, however, the decision to intervene depends mainly on the onset of symptoms, left ventricular function and dimensions, and any dilatation of the aorta.
It is therefore incorrect to think that a leaking valve must always be operated on, but it is also incorrect to wait for symptoms in every case. In severe aortic regurgitation, the heart can compensate for years and begin to dilate before the person notices any obvious deterioration.

This guide focuses on the timing of intervention. For causes, mechanisms and complete classification, see the monograph on aortic regurgitation.

What severe aortic regurgitation means

In aortic regurgitation, some of the blood that has just been ejected into the aorta returns to the left ventricle during diastole because the valve does not close adequately. Over time, the ventricle has to accommodate a larger volume of blood and may progressively dilate.
Severity is not established by a single parameter. Echocardiography integrates the characteristics of the regurgitant jet, vena contracta, aortic flow, regurgitant volume and fraction, and the effects on the left ventricle. If the findings are discordant, cardiac magnetic resonance imaging or other investigations may be useful.

It is also important to assess the aortic root and ascending aorta. In particular, aortic regurgitation may be associated with a bicuspid aortic valve or aortic dilatation. In some patients, it is the size of the aorta that determines the surgical indication, independently of the severity of the regurgitation alone.

When symptoms favor intervention

If aortic regurgitation is severe and causes symptoms attributable to the valve disease, surgery is generally recommended when operative risk is not prohibitive. The most common symptoms are shortness of breath during exertion, reduced exercise capacity and fatigue; in more advanced stages, dyspnea at rest or signs of heart failure may develop.
Some people also report palpitations or a pronounced awareness of the heartbeat, but these symptoms alone cannot establish the severity of the valve disease.

A practical point is to determine whether the person is truly asymptomatic. Someone who slowly reduces their level of activity may not notice the change. In doubtful cases, when appropriate, the cardiologist may use an exercise test to assess functional capacity and the development of symptoms.

If there are no symptoms: the ventricular measurements that matter

In asymptomatic severe aortic regurgitation, monitoring the left ventricle is crucial. The 2025 ESC/EACTS guidelines recommend surgery when resting ejection fraction is 50% or less, or when left ventricular end-systolic diameter exceeds 50 mm or 25 mm/m² after indexing to body surface area, particularly in people of small body size.
These thresholds are intended to prevent intervention from being delayed until the ventricle has sustained damage that is more difficult to reverse.

The same guidelines recognize that in selected asymptomatic patients at low operative risk, even earlier intervention can be discussed when ejection fraction is 55% or less, indexed end-systolic diameter exceeds 22 mm/m², or indexed end-systolic volume exceeds 45 mL/m². This is an individualized decision, not a set of thresholds to be used independently to interpret a report.

When follow-up is enough and how often it should be repeated

If the regurgitation is not severe or, despite being severe, there are no criteria for intervention, follow-up is used to identify progression before it becomes clinically apparent. The frequency depends on severity, ventricular size and function, the aorta and the rate at which the parameters change over time.
In asymptomatic severe aortic regurgitation with preserved ventricular function, follow-up must be close, generally at least annually and more frequently when measurements approach intervention thresholds or show progression.

During follow-up, the echocardiogram is not the only consideration. The onset of new breathlessness, reduced exercise endurance, edema or rapid deterioration should be reported. Severe acute aortic regurgitation, by contrast, is a different situation from the chronic form and may require urgent assessment and treatment.

Medications, surgery and the possibility of transcatheter treatment

Medications do not repair a leaking aortic valve. They may be needed to treat hypertension, heart failure or other associated conditions, but ACE inhibitors or calcium-channel blockers have not been shown to safely postpone surgery when an indication for intervention is already present.
When intervention is required, the strategy may include valve replacement or, in selected patients at experienced centers, valve repair or valve-sparing procedures as part of aortic root surgery.

TAVI is well established for aortic stenosis, whereas the context is different in pure aortic regurgitation because the calcification that helps anchor conventional devices is often absent. The 2025 guidelines allow transcatheter treatment to be considered in selected patients with symptomatic severe aortic regurgitation who cannot undergo surgery, when the anatomy and available technology are suitable. The choice should be made by a Heart Team.

Frequently asked questions about aortic regurgitation

When does aortic regurgitation need surgery?
When regurgitation is severe and causes symptoms, or when the left ventricle reaches specific thresholds of function or dilatation. Significant aortic dilatation can also determine the surgical indication.

Does moderate aortic regurgitation need surgery?
Usually not. In the absence of other indications for cardiac surgery, it is generally monitored over time.

Can severe aortic regurgitation occur without symptoms?
Yes. The ventricle can compensate for a long time, which is why echocardiographic follow-up is important even when a person feels well.

Can medications avoid intervention?
There is no proven drug treatment capable of replacing surgery when an indication for intervention is already present. Medications are used for associated problems or to control symptoms in people who cannot undergo surgery.

Is TAVI also used for aortic regurgitation?
It may be considered in selected patients who are inoperable or at high risk, but it is not simply the same pathway used for aortic stenosis.