Multimodal Cardiac Imaging in Aortic Regurgitation: From Pathophysiology to Diagnosis and Treatment Planning

Aortic regurgitation (AR) is a complex and often misdiagnosed valvular heart disease. It is often asymptomatic for years, making early detection critical. Once symptoms develop, left ventricular dysfunction may already be irreversible. Timely and accurate grading of AR severity can guide clinical decision-making and improve survival rates. Delayed diagnosis increases the risk of heart failure, arrhythmias, and sudden cardiac death. Transthoracic echocardiography (TTE) is the first-line imaging modality, providing assessment of valve morphology, AR severity, left ventricular size and function, and aortic dimensions. When TTE is inconclusive or additional anatomical information is required, complementary imaging modalities provide incremental value. Transesophageal echocardiography often helps to define AR mechanism and is particularly relevant for valve repair assessment and procedural guidance. Cardiovascular magnetic resonance enables accurate quantification of regurgitant volume and fraction, detailed evaluation of ventricular remodeling, and detection of myocardial fibrosis. Cardiac computed tomography offers high-resolution characterization of the aorta and is increasingly important for surgical and transcatheter planning. In selected patients, multimodality imaging also helps evaluate prosthetic valve dysfunction and suspected infective endocarditis. This paper reviews the currently used imaging modalities and their clinical applicability, and proposes an integrated multimodality imaging approach to guide patient management in chronic AR.