Aortic Regurgitation

Aortic Regurgitation Severity

Integrative echo assessment of AR severity

Color Doppler

VC Vena contracta
Narrowest portion of the AR jet
cm
J Jet width / LVOT
Ratio of proximal AR jet width to LVOT diameter
%
Flow convergence
Proximal flow convergence on color Doppler

Doppler Findings

Pressure half-time
CW Doppler deceleration of the AR jet
ms
AR CW jet density
Spectral density of the regurgitant signal
Descending aortic flow reversal
Pulsed-wave Doppler in the descending thoracic aorta

Quantitative AR

Regurgitant volume
mL
Regurgitant fraction
%
EROA
Effective regurgitant orifice area
cm²

Structural Findings

Valve morphology
Flail leaflet or wide coaptation defect
LV dilation
Supports hemodynamically significant chronic AR
AR Severity Reference
Parameter Mild Moderate Severe
Vena contracta <0.30 cm 0.30–0.60 cm >0.60 cm
Jet width / LVOT <25% 25–64% ≥65%
PHT >500 ms 200–500 ms <200 ms
Descending aortic flow Brief early reversal Intermediate Prominent holodiastolic
Regurgitant volume <30 mL 30–59 mL ≥60 mL
Regurgitant fraction <30% 30–49% ≥50%
EROA <0.10 cm² 0.10–0.29 cm² ≥0.30 cm²
Grade II moderate AR: RVol 30–44 mL, RF 30–39%, or EROA 0.10–0.19 cm². Grade III moderate AR: RVol 45–59 mL, RF 40–49%, or EROA 0.20–0.29 cm².

Color Doppler: Jet Width & Vena Contracta

  • Jet Width / LVOT Diameter Ratio
    • Mild: <25%
    • Moderate: 25–64%
    • Severe: ≥65%
  • Vena Contracta Width
    • Mild: <0.3 cm
    • Moderate: 0.3–0.6 cm
    • Severe: >0.6 cm

Pressure Half-Time (PHT)

  • Measures rate of pressure equalization between LV & aorta.
    • Mild: >500 ms
    • Moderate: 200–500 ms
    • Severe: <200 ms

Holodiastolic Flow Reversal (Descending Aorta)

PW Doppler in descending aorta

  • Absent or brief: Mild
  • Holodiastolic reversal: Severe

Regurgitant Volume & Fraction 

  • Regurgitant Volume (RVol)
    • Mild: <30 mL
    • Moderate: 30–59 mL
    • Severe: ≥60 mL
  • Regurgitant Fraction (RF)
    • Mild: <30%
    • Moderate: 30–49%
    • Severe: ≥50%

LV Size & Function

  • Chronic severe AR → LV dilation (LVEDD >65 mm, LVESD >50 mm).
  • EF typically preserved until late; declining EF suggests decompensation.

Severe AR usually shows

  • Wide jet (>65% LVOT)
  • Vena contracta >0.6 cm
  • PHT <200 ms
  • Holodiastolic flow reversal
  • RVol ≥60 mL or RF ≥50%
  • LV dilation +/- decreased EF

References

  1. Zoghbi, W. A., Adams, D., Bonow, R. O., Enriquez-Sarano, M., Foster, E., Grayburn, P. A., Hahn, R. T., Han, Y., Hung, J., Lang, R. M., Little, S. H., Shah, D. J., Shernan, S., Thavendiranathan, P., Thomas, J. D., & Weissman, N. J. (2017). Recommendations for noninvasive evaluation of native valvular regurgitation: A report from the American Society of Echocardiography. Journal of the American Society of Echocardiography, 30(4), 303–371. https://doi.org/10.1016/j.echo.2017.01.007
  2. Lancellotti, P., Tribouilloy, C., Hagendorff, A., Moura, L., Popescu, B. A., Agricola, E., Monin, J. L., Pierard, L. A., Badano, L., & Zamorano, J. L. (2013). Recommendations for the echocardiographic assessment of native valvular regurgitation: An executive summary from the European Association of Cardiovascular Imaging. European Heart Journal Cardiovascular Imaging, 14(7), 611–644. https://doi.org/10.1093/ehjci/jet105
  3. Otto, C. M., Nishimura, R. A., Bonow, R. O., Carabello, B. A., Erwin, J. P., III, Gentile, F., Jneid, H., Krieger, E. V., Mack, M., McLeod, C., O’Gara, P. T., Rigolin, V. H., Sundt, T. M., III, & Thompson, A. (2021). 2020 ACC/AHA guideline for the management of patients with valvular heart disease. Circulation, 143(5), e72–e227. https://doi.org/10.1161/CIR.0000000000000923
  4. Praz, F., Borger, M. A., Lanz, J., Marin-Cuartas, M., Abreu, A., Adamo, M., Ajmone Marsan, N., Barili, F., Bonaros, N., Cosyns, B., De Paulis, R., Gamra, H., Jahangiri, M., Jeppsson, A., Klautz, R. J. M., Mores, B., Pérez-David, E., Pöss, J., Prendergast, B. D., ... Wojakowski, W. (2025). 2025 ESC/EACTS guidelines for the management of valvular heart disease. European Heart Journal, 46(44), 4635–4736. https://doi.org/10.1093/eurheartj/ehaf194
  5. Bonow, R. O., Carabello, B. A., Chatterjee, K., de Leon, A. C., Jr., Faxon, D. P., Freed, M. D., Gaasch, W. H., Lytle, B. W., Nishimura, R. A., O’Gara, P. T., O’Rourke, R. A., Otto, C. M., Shah, P. M., & Shanewise, J. S. (2008). 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. Circulation, 118(15), e523–e661. https://doi.org/10.1161/CIRCULATIONAHA.108.190748