Heart Valve Disease

pic-vhd Heart Valve Disease

Heart valve disease is a disease in which one or more of your heart valves don't work properly. The heart has four valves: the tricuspid (tri-CUSS-pid), pulmonary (PULL-mun-ary), mitral (MI-trul), and aortic (ay-OR-tik) valves.

These valves have tissue flaps that open and close with each heartbeat. The flaps make sure blood flows in the right direction through your heart's four chambers and to the rest of your body.

The illustration shows a cross-section of a healthy heart, including the four heart valves. The blue arrow shows the direction in which oxygen-poor blood flows from the body to the lungs. The red arrow shows the direction in which oxygen-rich blood flows from the lungs to the rest of the body.

Birth defects, age-related changes, infections, or other conditions can cause one or more of your heart valves to not open fully or to let blood leak back into the heart chambers. This can make your heart work harder and affect its ability to pump blood.

Overview of Heart Valve Disease

How the Heart Valves Work

At the start of each heartbeat, blood returning from the body and the lungs fills the atria (the heart's two upper chambers). The mitral and tricuspid valves are located at the bottom of these chambers. As the blood builds up in the atria, these valves open to allow blood to flow into the ventricles (the heart's two lower chambers).

After a brief delay, as the ventricles begin to contract, the mitral and tricuspid valves shut tightly. This stops blood from flowing backward into the atria.

As the ventricles contract, they pump blood through the pulmonary and aortic valves. The pulmonary valve opens to allow blood to flow from the right ventricle into the pulmonary artery. This artery carries blood to the lungs to get oxygen.

At the same time, the aortic valve opens to allow blood to flow from the left ventricle into the aorta. The aorta carries oxygen-rich blood to the body. As the contraction ends, the pulmonary and aortic valves shut tightly. This stops blood from flowing backward into the ventricles.

Heart Valve Problems

Heart valves can have three basic kinds of problems: regurgitation (re-GUR-ji-TA-shun), stenosis (ste-NO-sis), and atresia (a-TRE-ze-ah).

Regurgitation, or backflow, occurs when a valve doesn't close tightly. Blood leaks back into the chambers rather than flowing forward through the heart or into an artery.

In the United States, backflow is most often due to prolapse. "Prolapse" is when the flaps of the valve flop or bulge back into an upper heart chamber during a heartbeat. Prolapse mainly affects the mitral valve.

Stenosis occurs when the flaps of a valve thicken, stiffen, or fuse together. This prevents the heart valve from fully opening. As a result, not enough blood flows through the valve. Some valves can have both stenosis and backflow problems.

Atresia occurs when a heart valve lacks an opening for blood to pass through.

You can be born with heart valve disease, or you can acquire it later in life. Heart valve disease that develops before birth is called congenital (kon-JEN-i-tal) heart valve disease. Congenital heart valve disease can occur alone or with other congenital heart defects.

Congenital heart valve disease usually involves pulmonary or aortic valves that don't form properly. These valves may not have enough tissue flaps, they may be the wrong size or shape, or they may lack an opening through which blood can flow properly.

Acquired heart valve disease usually involves the aortic or mitral valve. Although the valve is normal at first, disease can cause problems to develop over time.

Both congenital and acquired heart valve disease can cause stenosis or backflow.

Outlook

Many people have heart valve defects or disease but don't have symptoms. For some people, the condition mostly stays the same throughout their lives and doesn't cause any problems.

For other people, the condition slowly worsens until symptoms develop. If not treated, advanced heart valve disease can cause heart failure, stroke, blood clots, or sudden death due to sudden cardiac arrest (SCA).

Currently, no medicines can cure heart valve disease. However, lifestyle changes and medicines can relieve many of the symptoms and problems linked to heart valve disease.

These treatments also can lower your risk of developing a life-threatening condition, such as stroke or SCA. Eventually, you may need to have your faulty heart valve repaired or replaced.

Some types of congenital heart valve disease are so severe that the valve is repaired or replaced during infancy, childhood, or even before birth. Other types may not cause problems until you're middle-aged or older, if at all.

Signs and Symptoms

Major Signs and Symptoms

The main sign of heart valve disease is an unusual heartbeat sound called a heart murmur. Your doctor can hear a heart murmur with a stethoscope.

However, many people have heart murmurs without having heart valve disease or any other heart problems. Others may have heart murmurs due to heart valve disease, but have no other signs or symptoms.

Heart valve disease often worsens over time, so signs and symptoms may develop years after a heart murmur is first heard. Many people who have heart valve disease don't have any symptoms until they're middle-aged or older.

Other common signs and symptoms of heart valve disease relate to heart failure, which heart valve disease can eventually cause. These symptoms include:

  • Unusual fatigue (tiredness)
  • Shortness of breath, especially when you exert yourself or when you're lying down
  • Swelling in your ankles, feet, legs, abdomen, and veins in the neck

Other Signs and Symptoms

Heart valve disease can cause chest pain that may only happen when you exert yourself. You also may notice a fluttering, racing, or irregular heartbeat. Some types of heart valve disease, such as aortic or mitral valve stenosis, can cause dizziness or fainting.

Diagnosis

Your primary care provider may detect a heart murmur or other signs of heart valve disease. However, a cardiologist usually will diagnose the condition. A cardiologist is a doctor who specializes in diagnosing and treating heart problems.

To diagnose heart valve disease, your doctor will ask about your signs and symptoms. He or she also will do a physical exam and look at the results from tests and procedures.

Physical Exam

Your doctor will listen to your heart with a stethoscope to find out whether you have a heart murmur that's likely caused by a heart valve problem.

Your doctor also will listen to your lungs as you breathe to check for fluid buildup. He or she will check for swollen ankles and other signs that your body is retaining water.

Tests and Procedures

The main test for diagnosing heart valve disease is echocardiography (echo). But an EKG (electrocardiogram) or chest x ray is commonly used to reveal certain signs of the condition. If these signs are present, echo usually is done to confirm the diagnosis.

Your doctor also may recommend other tests, such as cardiac catheterization, stress testing, or cardiac MRI (magnetic resonance imaging), if you're diagnosed with heart valve disease. These tests and procedures can help your doctor better assess how severe your condition is and plan treatment.

EKG

This simple test detects and records the heart's electrical activity. An EKG can detect an irregular heartbeat and signs of a previous heart attack. It also can show whether certain chambers of your heart are enlarged.

An EKG usually is done in a doctor's office.

Chest X Ray

This test can show whether certain sections of your heart are enlarged, whether you have fluid in your lungs, or whether there are calcium deposits in your heart.

A chest x ray helps your doctor learn which type of valve defect you have, how severe it is, and whether you have any other heart problems.

Echocardiography

Echo uses sound waves to create a moving picture of your heart as it beats. A device called a transducer is placed on the surface of your chest.

The transducer sends sound waves through your chest wall to your heart. Echoes from the sound waves are converted into pictures of your heart on a computer screen.

Echo can show:

  • The size and shape of your heart valves and chambers
  • How well your heart is pumping blood
  • Whether a valve is narrowed or has backflow

Your doctor may recommend transesophageal (tranz-ih-sof-uh-JEE-ul) echo, or TEE, to get a better image of your heart.

During TEE, the transducer is attached to the end of a flexible tube. The tube is guided down your throat and into your esophagus (the passage leading from your mouth to your stomach). You'll likely be given medicine to help you relax during this procedure.

Cardiac Catheterization

For this procedure, a long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck and threaded to your heart. Your doctor uses x-ray images to guide the catheter.

Through the catheter, your doctor does diagnostic tests and imaging that show whether backflow is occurring through a valve and how fully the valve opens. You're given medicine to help you relax, but you're awake during the procedure.

Your doctor may recommend cardiac catheterization if your signs and symptoms of heart valve disease aren't in line with your echo results.

The procedure also can help your doctor assess whether your symptoms are due to specific valve problems or coronary heart disease (also called coronary artery disease). All of this information helps your doctor decide the best way to treat you.

Stress Test

During stress testing, you exercise to make your heart work hard and beat fast while heart tests and imaging are done. If you can't exercise, you may be given medicine to make your heart work hard and beat fast.

A stress test can show whether you have signs and symptoms of heart valve disease when your heart is working hard. It can help your doctor assess the severity of your heart valve disease.

Cardiac MRI

Cardiac MRI uses a powerful magnet and radio waves to make detailed images of your heart. A cardiac MRI image can confirm information about valve defects or provide more detailed information.

This information can help your doctor plan your treatment. An MRI also may be done before heart valve surgery to help your surgeon plan for the surgery.

Treatment

The goals of heart valve disease treatment include:

  • Preventing, treating, or relieving the symptoms of other related heart conditions.
  • Protecting heart valves from further damage.
  • Repairing or replacing faulty valves when they cause severe symptoms or become life threatening. Man-made or biological valves are used as replacements.

Currently, no medicines can cure heart valve disease. However, lifestyle changes and medicines often can treat symptoms successfully and delay complications for many years. Eventually, though, you may need surgery to repair or replace a faulty heart valve.

Preventing, Treating, or Relieving the Symptoms of Other Related Heart Conditions

To relieve the symptoms of heart conditions related to heart valve disease, your doctor may ask you to quit smoking and follow a healthy diet.

A healthy diet includes a variety of fruits, vegetables, and whole grains or you could even add a garlic supplement to your diet to help with a healthy heart. It also includes lean meats, poultry, fish, beans, and fat-free or low-fat milk or milk products. A healthy diet is low in saturated fat, trans fat, cholesterol, sodium (salt), and added sugar.

For more information about following a healthy diet, see the National Heart, Lung, and Blood Institute's Aim for a Healthy Weight Web site, “Your Guide to a Healthy Heart,” and “Your Guide to Lowering Your Blood Pressure With DASH.” All of these resources include general information about healthy eating.

Your doctor also may ask you to limit physical activities that make you unusually short of breath and tired. He or she also may ask that you limit competitive athletic activity, even if the activity doesn't leave you unusually short of breath or tired.

Your doctor may prescribe medicines to help prevent or treat other related heart conditions, such as heart failure, high blood pressure, arrhythmia (an irregular heartbeat), coronary heart disease (CHD), and life-threatening blood clots. Heart valve disease can cause these conditions or worsen them.

People who have heart valve disease are commonly prescribed medicines to:

  • Treat heart failure. Heart failure medicines widen blood vessels and rid the body of excess fluid.
  • Lower their blood pressures or total blood cholesterol levels.
  • Prevent arrhythmias.
  • Thin their blood and prevent clots (for people who have man-made replacement valves). These medicines also are prescribed for mitral stenosis or other valve defects that raise your risk of blood clots.

Protecting Heart Valves From Further Damage

If you've had previous heart valve disease and now have a man-made valve, you may be at increased risk for a heart infection called infective endocarditis (IE). This infection can worsen your heart valve disease. Even if you don't yet have symptoms of a valve problem, you're at increased risk for IE.

One of the most common causes of IE is poor dental hygiene. Thus, to prevent this serious infection, it's important to floss and brush your teeth and see a dentist regularly. Gum infections and tooth decay can increase the risk of IE.

Let your doctors and dentists know if you have a man-made valve or if you've had IE before. They may give you antibiotics before dental procedures (such as dental cleanings) that could allow bacteria to enter your bloodstream. Talk to your doctor about whether you need to take antibiotics before such procedures.

Repairing or Replacing Heart Valves

Your doctor may recommend repairing or replacing your heart valve(s), even if you do not yet have symptoms of heart valve disease. This can prevent lasting damage to your heart and sudden death.

Having heart valve repair or replacement depends on a number of factors, including:

  • How severe your valve disease is.
  • Your age and general health.
  • Whether you need heart surgery for other conditions, such as bypass surgery to treat CHD. Bypass surgery and valve surgery can be done at the same time.

When possible, heart valve repair is preferred over heart valve replacement. Valve repair preserves the strength and function of the heart muscle. People who have valve repair also have a lower risk of IE after the surgery, and they don't need to take blood-thinning medicines for the rest of their lives.

However, heart valve repair surgery is harder to do than valve replacement. Also, not all valves can be repaired. Mitral valves often can be repaired. Aortic and pulmonary valves often have to be replaced.

Repairing Heart Valves

Heart valves can be repaired by:

  • Separating fused valve flaps
  • Removing or reshaping tissue so the valve can close tighter
  • Adding tissue to patch holes or tears or to increase the support at the base of the valve

Heart surgeons do most heart valve repair surgeries. Cardiologists do some repair surgeries using cardiac catheterization. Although catheterization procedures are less invasive, they also may not work as well for some patients.

You and your doctor will decide whether repair is appropriate and what the best procedure is for doing it.

Balloon valvuloplasty

Heart valves that don't open fully (stenosis) can be repaired with surgery or with a less invasive catheter procedure called balloon valvuloplasty (VAL-vyu-lo-plas-tee). This procedure also is called balloon valvotomy (val-VOT-o-me).

During the procedure, a balloon-tipped tube is threaded through your blood vessels and into the faulty valve in your heart. The balloon is inflated to help widen the opening of the valve. Your doctor then deflates the balloon and removes both it and the tube.

You're awake during the procedure, which usually requires an overnight stay in the hospital.

Balloon valvuloplasty relieves many of the symptoms of heart valve disease, but it may not cure it. The condition can still worsen over time. You may need medicines to help with symptoms or surgery to repair or replace the faulty valve.

Balloon valvuloplasty has a shorter recovery time than surgery. For some patients who have mitral valve stenosis, it may work as well as surgical repair or replacement. For these reasons, balloon valvuloplasty usually is preferred over surgical repair or replacement for these people.

Balloon valvuloplasty doesn't work as well as surgical treatment for adults who have aortic valve stenosis.

Balloon valvuloplasty often is used in infants and children. In these patients, congenital defects cause valve stenosis. Doctors can repair the defects using balloon valvuloplasty.

Replacing Heart Valves

Sometimes heart valves can't be repaired and must be replaced. This surgery involves removing the faulty valve and replacing it with a man-made or a biological valve.

Biological valves are made from pig, cow, or human heart tissue and may have parts as well. These valves are specially treated, so no medicines are needed to stop the body from rejecting the valve.

Man-made valves are more durable than biological valves and usually don't have to be replaced. Biological valves usually have to be replaced after about 10 years, although newer biological valves may last 15 years or longer.

Unlike biological valves, however, man-made valves require you to take blood-thinning medicines for the rest of your life. These medicines prevent blood clots from forming on the valve. Blood clots can cause a heart attack or stroke. Man-made valves also raise your risk of IE.

You and your doctor will decide together whether you should have a man-made or biological replacement valve.

If you're a woman of childbearing age or if you're athletic, you may prefer a biological valve so you don't have to take blood-thinning medicines. If you're elderly, you also may prefer a biological valve, as it will likely last for the rest of your life.

Other Approaches for Repairing and Replacing Heart Valves

Some newer forms of heart valve repair and replacement surgery are less invasive than traditional surgery. These procedures use smaller incisions (cuts) to reach the heart valves. Hospital stays for these newer types of surgery usually are 3 to 5 days, compared with 5-day stays for traditional heart valve surgery.

New surgeries tend to cause less pain and have a lower risk of infection. Recovery time also tends to be shorter—2 to 4 weeks versus 6 to 8 weeks for traditional surgery.

Some cardiologists and surgeons are exploring procedures that use cardiac catheterization to thread clips or other devices in a tube through your blood vessels and into the faulty valve in your heart. The clips or devices are used to reshape the valve and stop the backflow of blood. It's not yet known how well these procedures work.

The Ross operation is a surgical procedure to treat faulty aortic valves. During this operation, your doctor removes your faulty aortic valve and replaces it with your pulmonary valve. The pulmonary valve is then replaced with a pulmonary valve from a deceased human donor.

This is more involved surgery than typical valve replacement, and it has a greater risk of complications.

The Ross operation may be especially useful for children because the surgically replaced valves continue to grow with the child. Also, lifelong treatment with blood-thinning medicines isn't required.

But in some patients, one or both valves fail to work properly within a few years of the surgery. Experts continue to debate the usefulness of this procedure.

Serious risks from all types of heart valve surgery vary according to your age, health, the type of valve defect(s) you have, and the surgical procedure(s) done.