Possible to have symptoms with moderate AR?

[MaryKL]

My daughter has just turned six and is being followed for aortic regurgitation secondary to valve damage done by a VSD (surgically closed). At various times it has been classified as mild or mild-moderate. Right now they are classifying her with moderate AR because she has pan-diastolic retrograde flow, enlarged LV (z score of 2.8), and a regurgitation jet measured at 3.1 (cm I think?).  Her LV z-score and regurgigant jet have worsened with every echo, otherwise all other parameters have looked relatively stable. Her cardiac function (ejection fraction and shortening fraction etc.) all look completely normal. He said he didn't know why her LV is enlarged, and that it is not related to her AR. (This is a new cardiologist as we recently moved).

He then asked if she has any symptoms and I told him that she is tiring much more easily (all of sudden back to falling asleep in the car, sleeping in later) and is showing decreasing stamina during typical play. She gets out of breath when on the playground or running around with siblings pretty quickly, but it doesn't seem to bother her and she doesn't complain of any pain or feeling poorly. It's pronounced enough that family members and neighbors/friends are commenting on it constantly and asking me if she's sick or if she's coming down with something. She's constantly complaining she's "tired", laying around for awhile (15-20 min) and then bouncing back up to happily play. We did take her to the pediatrician and they ruled out thyroid issues, anemia, and mono.

The cardiologist told me that it is not possible for mild-to-moderate AR to cause symptoms and that symptoms like I am describing can only be seen with severe AR. Is it possible for moderate AR to cause symptoms like I am describing? This is a very noticeable decline in the past 6-8 months and I've always been taught to look for horses before zebras. Before I start chasing down obscure and random, I'd like to make sure we've thoroughly examined the most obvious.

[MaryKL]

Thank you for your feedback; it is very helpful in formulating a plan from herein out.

Sincerely,
Mary

[Marie M Gleason, M.D.]

Your cardiologist is correct that in most cases of mild to moderate aortic regurgitation, there are no clinical symptoms seen in the patient.  However, if your daughter's echocardiogram shows an increasing left ventricular z-score serially, and she has had exercise intolerance that is noticeable (without other cause on tests performed by your pediatrician), then it is reasonable to assume that her aortic regurgitation is becoming problematic, and is likely closer to severe in grade.  I would recommend a cardiac MRI to assess the LV volume and ejection fraction as well as the aortic valve regurgitant volume.  If severe, then consideration of surgery to repair or replace the aortic valve needs to be entertained.  If the valve leakage is graded as "moderate" but the LV is dilated, and she is not on any medication at present, then one could institute an afterload reducing agent like enalapril to try to improve the efficiency of the heart.  If you are not satisfied with the opinion of your current cardiologist, based on your observations of your daughter's behavior, then please get a second opinion.