Valves

What is Valvular Heart Disease?

Valvular heart disease is when one or more of the four heart valves don’t work properly. Heart valve disorders can arise from two main types of problems:

Regurgitation

or leaking of the heart valve. When the valve doesn’t close completely, blood can flow backward through the valve. This reduces forward blood flow and can lead to volume overload of the heart chambers

Stenosis

or narrowing of the valve. When the valve doesn’t open properly it limits the flow of blood out of the ventricles or atria. The heart muscle then needs to use increased force to move blood through the narrowed valve.

Stenosis and regurgitation can occur in more than one valve at a time and both pathologies can also occur in the same valve.

How many heart valves are there?

There are four heart valves – the mitral, aortic, tricuspid and pulmonary valves. The aortic and mitral valves are most commonly affected.

Mitral valve:

The mitral valve is located between the left atrium and the left ventricle of the heart. The mitral valve opens as blood flows from the left atrium into the left ventricle during relaxation of the ventricle and closes as the left ventricle contracts to pump blood through the aorta to the rest of the body. A normal mitral valve has 2 leaflets.

Aortic valve:

The aortic valve is located between the left ventricle (in the outflow tract) and the aorta. The aortic valve opens when the left ventricle contracts to pump blood through the aorta to the rest of the body and then closes when that contraction is complete. A normal aortic valve has 3 leaflets.

Tricuspid valve:

The tricuspid valve is located between the right atrium and right ventricle. The tricuspid valve opens as blood flows from the right atrium into the right ventricle during relaxation of the ventricle and closes as the right ventricle contracts to pump blood through the pulmonary arteries into the lungs. A normal tricuspid valve has three leaflets.

Pulmonary valve:

The pulmonary valve is located between the right ventricle (in the outflow tract) and the main pulmonary artery. The pulmonary valve opens when the right ventricle contracts to pump blood through the main pulmonary artery into the lungs and then closes when that contraction is complete. A normal pulmonary valve has 3 leaflets.

What are the symptoms of Valvular Heart Disease?

Mild to moderate heart valve disease may not cause any symptoms. These are the most common symptoms of heart valve disease:

• Shortness of breath
• Pain, tightness or pressure in the chest
• Palpitations caused by irregular heartbeats
• Fatigue
• Dizziness or light-headedness
• Fainting or collapse
• Abdominal pain due to an enlarged liver (if there is tricuspid valve malfunction)
• Swollen ankles or feet
• Not being able to do the activities you once did
• Unable to sleep lying flat

What are the risk factors of Valvular Heart Disease?

• Older age
• Coronary artery disease and heart attacks and other heart conditions
• Heart valve infection (endocarditis)
• Rheumatic fever
• High blood pressure and other coronary artery disease risk factors such as smoking, diabetes and high cholesterol
• Congenital heart valve disease (eg bicuspid aortic valve when you are born with 2 rather than 3 leaflets)
• Previous radiation therapy
• Connective tissue diseases such as Marfans syndrome

How do you diagnose valvular heart disease?

History and physical examination can point your physician towards a diagnosis of valvular heart disease. Your doctor may be able to hear a heart murmur or detect clinical signs of heart failure.

A transthoracic echocardiogram is the mainstay of diagnosis in valvular heart disease. This is a specialised ultrasound of the heart which demonstrates the structure of the heart including the valve function and the blood flow within the heart.

Transoesophageal echocardiogram can also be performed whereby the ultrasound probe is inserted under sedation in the oesophagus which lies behind the heart in the chest cavity and allows a closer look at some of the structures whilst some are better seen via the external echocardiogram.

Cardiac MRI can be performed to help assist with diagnosis of underlying cardiomyopathies and look for other associated conditions such as congenital shunts and other abnormal cardiac and extracardiac connections and associated pathologies in the aorta. Cardiac MRI can also assist with assessment of the severity of valvular heart disease.

An electrocardiogram or ECG can assist with diagnosis of valvular heart disease by revealing evidence of previous heart attacks, abnormal heart rhythms which can be associated with valvular heart disease etc.

Chest X ray can demonstrate signs of heart failure which can be associated with valvular heart disease and enlargement of the heart chambers.

How do you treat valvular heart disease?

Heart valve disease treatment depends on your symptoms, the severity of the condition, and whether your condition is worsening. Treatment might include monitoring your condition with regular follow-up visits. You might be asked to make healthy lifestyle changes

Medications

Medications are not a cure for valvular heart disease but they can be used to treat symptoms. Blood thinners may be used to reduce the risk of blood clots if you have a certain irregular heart rhythm.

Surgery

You might eventually need heart valve surgery to repair or replace the diseased heart valve even if you don’t have symptoms. If you need surgery for another heart condition, your doctor might repair or replace the diseased valve at the same time. Surgery is performed by a cardiothoracic surgeon.

Surgery may be necessary to repair or replace the malfunctioning valve(s). Surgery may include minimally invasive heart surgery or open-heart surgery (full sternotomy).

Surgical options include valve repair or replacement: If the valve can’t be repaired, surgeons might remove the damaged valve and replace it with a mechanical valve or a valve made from cow, pig or human heart tissue (biological or tissue valve). If you had valve replacement with a mechanical valve, you’ll need to take blood thinners for the rest of your life to prevent blood clots. Biological tissue valves break down over time and may need to be replaced.

Catheter-Based, Non-invasive Treatments: These treatments are performed by interventional cardiologists and this field of treatment is relatively new and rapidly evolving.

Transcatheter aortic valve replacement (TAVR) is a minimally invasive treatment option using a catheter-based approach for intermediate and high-risk patients with severe aortic stenosis. This procedure was first performed in 2002.

MitraClip involves performing a percutaneous procedure using the MitraClip system for patients with severe mitral regurgitation. who may be too high risk for standard open-heart surgery.