Aortic regurgitation assessment
AR severity is graded by integrating colour Doppler, CW Doppler, aortic flow reversal, vena contracta, quantitative measures, LV response, blood pressure, and image quality.
Clinically reviewed 23 May 2026 · EchoRapp clinical content
Simple approach
Use the AR panel as a pattern check, not as a single-number calculator. First confirm true diastolic aortic regurgitation. Then decide whether the study is clearly mild, clearly severe, or still needs more evidence.
| Panel item | How to use it |
|---|---|
| Regurgitation grade | Final integrated grade entered after reviewing all evidence |
| Jet direction | Explains why colour Doppler and VC may be reliable or difficult |
| Pressure half-time | Supportive only; short PHT supports severe AR, long PHT supports mild AR |
| Regurgitation fraction | Quantitative burden when Doppler stroke volumes are reliable |
| Vena contracta | Useful semi-quantitative marker at the narrowest jet neck |
| Descending aorta reversal | Holodiastolic reversal, especially with V_ED ≥ 20 cm/s, supports severe AR |
| Abdominal aorta reversal | Highly specific for severe AR if other causes are excluded |
| Evidence panel | Shows which severe-AR markers are present, missing, or discordant |
| Missing fields | Try to fill EROA, regurgitant volume, echo RF, and holodiastolic Ao desc. V_ED when AR is more than mild |
A clearly mild pattern is a small central jet, reassuring VC/PHT, no meaningful diastolic aortic reversal, and no LV volume response. A clearly severe pattern has several concordant markers: large or eccentric jet, VC ≥ 6 mm, PHT < 200 ms, EROA ≥ 30 mm2, RVol ≥ 60 ml, RF ≥ 50%, or strong aortic flow reversal.
Info
Integrative grading means the final AR grade should match the images, Doppler measurements, aortic flow reversal, LV size/function, blood pressure, and image quality. No single measurement should decide severity alone.
If the entered grade and the evidence panel disagree, go back to the loops. In AR, discordance is common and usually means one of three things: the jet is eccentric, the Doppler data are incomplete, or loading conditions are changing the signal.
Detailed tutorial
Start with anatomy. Look at cusp number and motion, coaptation, prolapse or flail, endocarditis, root dilatation, and the ascending aorta. The 2025 ESC/EACTS guideline emphasizes that AR evaluation should cover severity, mechanism, haemodynamic impact on the LV and pulmonary pressure, and the ascending aorta.
Then grade severity in layers.
| Marker | Supports mild AR | Supports severe AR |
|---|---|---|
| Colour jet | Small central jet | Large central jet or important eccentric jet |
| Jet/LVOT width | Small | ≥ 65% in a central jet |
| Vena contracta | < 3 mm | ≥ 6 mm |
| Pressure half-time | > 500 ms | < 200 ms |
| EROA | < 10 mm2 | ≥ 30 mm2 |
| Regurgitant volume | < 30 ml | ≥ 60 ml |
| Echo regurgitant fraction | Low | ≥ 50% |
| LV response | Normal LV in chronic AR supports non-severe AR | LV dilatation or falling EF supports chronic severe AR |
Colour Doppler is best for finding the jet and understanding direction. Do not grade by jet area alone. Eccentric jets can look deceptively small, especially when they hug the septum or anterior mitral leaflet.
VC and PISA are strongest when the jet neck and flow convergence are clearly seen. If PISA geometry is poor, do not force the number. In borderline or discordant cases, CMR can help quantify regurgitant volume and fraction.
| Flow reversal | Interpretation |
|---|---|
| Brief protodiastolic reversal in upper descending aorta | Can be normal or mild; not specific for severe AR |
| Holodiastolic reversal in upper descending aorta | Supports at least moderate AR |
| End-diastolic reverse velocity ≥ 20 cm/s | Strongly supports severe AR |
| Any diastolic reversal in abdominal aorta | Highly specific for severe AR if other causes are excluded |
| No abdominal reversal | Does not exclude severe AR |
Warning
Pressure half-time is affected by acute versus chronic AR, LV diastolic pressure, systemic vascular resistance, blood pressure treatment, heart rate, Doppler alignment, and aortic compliance or stiffness. Treat it as supportive, not decisive.
| Pitfall | Practical response |
|---|---|
| Severe-looking colour jet but no quantitative data | Add VC, PHT, EROA/RVol/RF, and aortic flow reversal if feasible |
| Eccentric jet looks small | Use multiple views and rely more on VC, PISA if valid, and flow reversal |
| Short PHT in acute AR | Remember the LV may still be normal sized |
| High blood pressure during the exam | AR and RVol may be overestimated |
| Severe chronic AR with normal LV size | Recheck severity, chronicity, and image quality |
| Abdominal reversal marked present | Confirm true diastolic reversal and exclude other causes |
Finally, check the LV and aorta. Chronic severe AR usually produces LV volume loading, so report LV diameters, volumes, indexed values, EF, and trends when available. Also measure the annulus, sinuses, sinotubular junction, and ascending aorta, because root or ascending aortic disease may drive both mechanism and management.
References
- Fabien Praz et al. 2025 ESC/EACTS Guidelines for the management of valvular heart disease. European Heart Journal 2025;46(44):4635–4736. View guideline
- Patrizio Lancellotti et al. Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of Cardiovascular Imaging. European Heart Journal – Cardiovascular Imaging 2013;14(7):611–644. View guideline