Heart Valve Diseases

What is heart valve disease?

Heart valve disease is when one or more heart valves don’t work right. The valves normally keep blood flow moving forward in one direction. And they prevent the backward flow of blood as it leaves each chamber of the heart. The heart has 4 chambers: 2 upper chambers (atria) and 2 lower chambers (ventricles). The heart also has 4 valves. They are:

• Tricuspid valve. Located between the right atrium and the right ventricle.

• Pulmonary valve. Located between the right ventricle and the pulmonary artery.

• Mitral valve. Located between the left atrium and the left ventricle.

• Aortic valve. Located between the left ventricle and the aorta.

As the heart muscle contracts and relaxes, the valves open and close, letting blood flow into the ventricles and out to the body at alternate times. The following is a step-by-step explanation of blood flow through the heart:

1. The left and right atrium contract once they are filled with blood. This pushes open the mitral and tricuspid valves. Blood is then pumped into the ventricles.

2. The left and right ventricles contract. This closes the mitral and tricuspid valves, preventing backward blood flow. At the same time, the aortic and pulmonic valves open to let blood be pumped out of the heart.

3. The left and right ventricles relax. The aortic and pulmonic valves close, preventing backward blood flow into the heart. The mitral and tricuspid valves then open to allow forward blood flow within the heart to fill the ventricles again.

Heart valve disease can occur from 2 main types of problems:

• Leakage of the valve (regurgitation or insufficiency). When the valve does not close completely, it causes blood to flow backward through the valve. This reduces forward blood flow and can lead to volume overload in the heart.

• Narrowing of the valve (stenosis). When the valve opening becomes narrowed, it limits the blood flow out of the ventricles or atria. The heart is forced to pump blood with more force to move blood through the narrowed or stiff (stenotic) valve.

Heart valves can develop both regurgitation and stenosis at the same time. Also, more than one heart valve can be affected at the same time. Some of the more common heart valve diseases are:

• Bicuspid aortic valve. With this birth defect, the aortic valve has only 2 leaflets instead of 3. It's more likely to narrow over time. If the valve becomes narrowed, it is harder for the blood to flow through. Often the aortic valve may also develop regurgitation in addition to stenosis. Symptoms often don’t appear until the adult years.

• Mitral valve prolapse. With this defect, the mitral valve leaflets bulge and don’t close correctly during the contraction of the heart. This may lead to a lot of regurgitation over time.

• Mitral valve stenosis. With this problem, the mitral valve opening is narrowed. It's often caused by a history of rheumatic fever. It increases resistance to blood flow from the left atrium to the left ventricle.

• Aortic valve stenosis. This valve disease occurs mainly in older adults. It causes the aortic valve opening to narrow. This increases resistance to blood flow from the left ventricle to the aorta.

• Pulmonary stenosis. With this valve disease, the pulmonary valve does not open enough. This forces the right ventricle to pump harder and enlarge. This is often a condition that is present at birth (congenital).

What causes heart valve disease?

The causes of heart valve disease include:

• Changes in the heart valve structure because of aging

• Coronary artery disease and heart attack

• Heart valve infection (endocarditis)

• Birth defect

• A sexually transmitted infection (syphilis)

• An inherited connective tissue disorder that makes the heart valve tissue (myxomatous degeneration) weak

• Radiation, such as radiation therapy, aimed at the chest wall to treat lymphoma

• Medicines, such as the now-banned diet pill, fenfluramine/phentermine, commonly called Fen-Phen

What are the symptoms of heart valve disease?

You may not have any symptoms if you have mild to moderate heart valve disease. The most common symptoms are:

• Chest pain

• Fluttering heartbeat (palpitations)

• Severe tiredness (fatigue)

• Dizziness or fainting

• Low or high blood pressure, depending on the type of valve disease

• Shortness of breath with activity or rest

• Belly pain because of an enlarged liver (if the tricuspid valve isn’t working correctly)

• Swelling in the legs, ankles, feet, abdomen, or veins in the neck

Symptoms of heart valve disease may look like other health problems. Always see your healthcare provider for a diagnosis.

How is heart valve disease diagnosed?

Your healthcare provider may think you have heart valve disease if your heart doesn’t sound right through a stethoscope. They may hear abnormal sounds because of turbulent blood flow across a valve. This is called a heart murmur. It can often mean valve regurgitation or stenosis.

To further define the type of valve disease and extent of the valve damage, your healthcare provider may use any of the following tests:

• Electrocardiogram. This test records the electrical activity of the heart and shows abnormal rhythms (arrhythmias). It can also sometimes detect heart muscle damage.

• Echocardiogram (echo). This test uses sound waves (ultrasound) to evaluate the heart’s chambers and valves. An image on a screen is created as an ultrasound probe (transducer) is passed over the heart. This is the best test for looking at heart valve function.

• Transesophageal echocardiogram. A small ultrasound probe is passed down into the esophagus. The sound waves create an image of the valves and chambers of the heart on a computer screen without the ribs or lungs getting in the way.

• Chest X-ray. This test makes images of internal tissues, bones, and organs on film. An X-ray can show enlargement in any area of the heart.

• Cardiac catheterization. A tiny, hollow tube (catheter) is put through a large artery or vein in the leg or arm leading to the heart. It measures heart pressures. Contrast dye is injected so the healthcare provider can see images of the heart and blood vessels.

• MRI. This test uses a combination of large magnets, radio waves, and a computer to make images of organs and structures in the body.

• CT scan. This test uses X-rays and a computer to make images of organs and structures within the body. Contrast dye is often used to help make out the structures of the heart, including the heart valves.

• Stress test. This test records images of your heart before and after you exercise. If you are unable to exercise, medicine may be given to raise your heart rate. A stress test helps your healthcare provider evaluate your heart when it's working hard.

How is heart valve disease treated? 

In some cases, your healthcare provider may want only to closely watch the heart valve problem for a period of time. If you need treatment, it depends on the type of heart valve disease. Treatment may include:

Medicines

Medicines are not a cure for heart valve disease. But they can often ease symptoms. Beta-blockers, digoxin, and calcium channel blockers help to control heart rate and stop abnormal heart rhythms. Other medicines, such as diuretics or vasodilators, can help control blood pressure. These medicines may not work if you have a narrowed heart valve. Sometimes they can make symptoms worse. If the valve won’t open, you may need surgery, valvuloplasty, or transcatheter replacement.

Surgery

You may need surgery to fix or replace the valve that isn’t working right. In many cases, repair is preferable because your own tissues are used. When heart valves are severely malformed or destroyed, they may need to be replaced with a new valve. Replacement valves may be tissue (biologic) valves. These include animal valves and donated human valves. Or they may be mechanical valves. These are made of metal, plastic, or another artificial material.

Transcatheter procedures

These are minimally invasive procedures. The healthcare provider replaces the heart valves. It's done through an artery (for the aortic valve) or a vein (for the tricuspid, pulmonary, or mitral valve) and is often performed from the groin.

Heart valve repair

This repair is done for the mitral valve. A clip can be used to reduce the amount blood from leaking through the mitral valve.

Balloon valvuloplasty

For this nonsurgical procedure, a special hollow tube (catheter) is put into a blood vessel in the groin and guided into the heart. At the tip of the catheter is a deflated balloon that is inserted into the narrowed heart valve. Once in place, the balloon is inflated to stretch the valve open, and then removed. This procedure is only used to treat stenotic (narrowed) valves.

TAVR (transcatheter aortic valve replacement)

For this nonsurgical procedure, a new aortic valve is placed inside the older narrowed valve. This is done using catheters, balloons, and wires inserted through the arteries of the groin. Or in some cases, they may be inserted through the arteries of the arms or the apex of the heart. This procedure is currently used mostly for aortic stenosis, although it is being studied for use for aortic regurgitation. 

What are possible complications of heart valve disease?

When heart valves fail to open and close correctly, the effects on the heart can be serious. They may prevent the heart from pumping enough blood through the body. This may cause heart failure, abnormal heart rhythms, stroke, heart attack, or even death.

Key points about heart valve disease

• Heart valve disease is when one or more of the heart’s valves don’t work right.

• There are two main heart valve problems. A heart valve may leak (regurgitation). Or it may become narrowed (stenosis).

• One cause of heart valve disease is coronary artery disease and heart attack.

• Some common symptoms are chest pain, palpitations from irregular heartbeats, fatigue, shortness of breath, and dizziness.

• An echocardiogram is the best test for looking at heart valve function.

• Medicines may help ease symptoms. You may need a heart procedure or surgery to fix or replace a valve.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

• Know the reason for your visit and what you want to happen.

• Before your visit, write down questions you want answered.

• Bring someone with you to help you ask questions and remember what your provider tells you.

• At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you.

• Know why a new medicine or treatment is prescribed, and how it will help you. Also know what the side effects are.

• Ask if your condition can be treated in other ways.

• Know why a test or procedure is recommended and what the results could mean.

• Know what to expect if you do not take the medicine or have the test or procedure.

• If you have a follow-up appointment, write down the date, time, and purpose for that visit.

• Know how you can contact your healthcare provider if you have questions, especially after office hours or on weekends.