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Heart Valve Disease

Heart valve disease is a condition in which one or more of your heart valves don't work properly. The heart has four valves: the tricuspid, pulmonary, mitral, and aortic 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.

Healthy Heart Cross-Section
Healthy Heart Cross-Section

The illustration above 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

How the Heart Valves Work

At the start of each heartbeat, blood returning from the body and the lungs fills 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 upper chambers, these valves open to allow blood to flow into the lower chambers of your heart.

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

As the lower chambers contract, they pump blood through the pulmonary and aortic valves. The pulmonary valve opens to allow blood to flow from the right lower chamber 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 lower chamber into the aorta. This 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 lower chambers.

Heart Valve Problems

Heart valves can have three basic kinds of problems:

  • Regurgitation, or backflow, occurs when a valve doesn't close tightly. Blood leaks back into the chamber 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, but it can affect the other valves as well.
  • Stenosis occurs when the flaps of a valve thicken, stiffen, or fuse together. This prevents the heart valve from fully opening, and 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 a congenital 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 valves. 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 will stay largely the same over their lifetime and not cause any problems.

For other people, the condition will worsen slowly over time 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.

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. They also can lower your risk of developing a life-threatening condition, such as stroke or sudden cardiac arrest. 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 or childhood or even before birth. Other types may not cause problems until you're middle-aged or older, if at all.

Other Names for Heart Valve Disease

  • Aortic regurgitation
  • Aortic stenosis
  • Aortic sclerosis
  • Aortic valve disease
  • Bicuspid aortic valve
  • Congenital heart defect
  • Congenital valve disease
  • Mitral regurgitation
  • Mitral stenosis
  • Mitral valve disease
  • Mitral valve prolapse
  • Pulmonic regurgitation
  • Pulmonic stenosis
  • Pulmonic valve disease
  • Tricuspid regurgitation
  • Tricuspid stenosis
  • Tricuspid valve disease

What Causes Heart Valve Disease?

Heart conditions and other disorders, age-related changes, rheumatic fever, and infections can cause acquired heart valve disease. These factors change the shape or flexibility of once-normal valves.

The cause of congenital heart valve defects isn't known. These defects occur before birth as the heart is forming. Congenital heart valve defects can occur alone or with other types of congenital heart defects.

Heart Conditions and Other Disorders

Heart valves can be stretched and distorted by:

  • Damage and scar tissue due to a heart attack or injury to the heart.
  • Advanced high blood pressure and heart failure. These conditions can enlarge the heart or the main arteries.
  • Narrowing of the aorta due to the buildup of a fatty material called plaque inside the artery. The aorta is the main artery that carries oxygen-rich blood to the body. The buildup of plaque inside an artery is called atherosclerosis.

Age-Related Changes

Men older than 65 and women older than 75 are prone to developing calcium and other deposits on their heart valves. These deposits stiffen and thicken the valve flaps and limit blood flow (stenosis).

The aortic valve is especially prone to this problem. The deposits resemble those seen in the narrowed and hardened blood vessels of people who have atherosclerosis. Some of the same processes may cause both atherosclerosis and heart valve disease.

Rheumatic Fever

Some people have heart valve disease due to untreated strep throat or other infections with strep bacteria, which progress to rheumatic fever.

When the body tries to fight the strep infection, one or more heart valves may be damaged or scarred in the process. The aortic and mitral valves are most often affected. Symptoms due to heart valve damage often don't appear until many years after recovery from rheumatic fever.

Today, most people with strep infections are treated with antibiotics before rheumatic fever develops. It's very important to take the entire amount of antibiotics your doctor prescribes for strep throat, even if you feel better.

Heart valve disease due to rheumatic fever mainly affects older people who had strep infections before antibiotics were available. It also affects people from developing countries, where rheumatic fever is more common.

Infections

Common germs that enter through the bloodstream and get carried to the heart can sometimes infect the inner surface of the heart, including the heart valves. This rare, but sometimes life-threatening infection is called endocarditis.

The germs can enter the bloodstream through needles, syringes, or other medical devices and through breaks in the skin or gums. Usually the body's defenses fight off the germs and no infection occurs. Sometimes these defenses fail, which leads to endocarditis.

Endocarditis can develop in people who already have abnormal blood flow through a heart valve due to congenital or acquired heart valve disease. The abnormal blood flow causes blood clots to form on the surface of the valve. The blood clots make it easier for germs to attach to and infect the valve.

Endocarditis can worsen existing heart valve disease.

Other Conditions and Factors Linked To Heart Valve Disease

A number of other conditions and factors are sometimes linked to heart valve disease. However, it's often unknown how these conditions actually cause heart valve disease.

  • Systemic lupus erythematosis (SLE). SLE and other immune diseases can affect the aortic and mitral valves.
  • Carcinoid syndrome. Tumors in the digestive tract that spread to the liver or lymph nodes can affect the tricuspid and pulmonary valves.
  • Metabolic disorders. Relatively uncommon diseases, such as Fabry disease and hyperlipidemia, can affect the heart valves.
  • Diet medicines. The use of fenfluramine and phentermine ("fen-phen") has sometimes been linked to heart valve problems. These problems typically stabilize or improve after the medicine is stopped.
  • Radiation therapy. Radiation therapy to the chest area can cause heart valve disease. This therapy is used to treat cancer. Heart valve disease due to radiation therapy may not cause symptoms for as many as 20 years after the therapy ends.
  • Marfan syndrome. Congenital disorders, such as Marfan syndrome, and other connective tissue disorders mainly affect the structure of the body's main arteries. However, these conditions also can also affect the heart valves.

Who Is At Risk for Heart Valve Disease?

Populations Affected

Older people are more likely to develop heart valve disease. It's estimated that 1 in 8 people age 75 or older have at least moderate heart valve disease.

People who have a history of endocarditis, rheumatic fever, heart attack, or heart failure - or previous heart valve disease - are more likely to develop heart valve disease.

About 1 to 2 percent of people are born with an aortic valve that has two flaps instead of three. Sometimes an aortic valve may have three flaps, but two flaps are fused together and act as one flap. This is called a bicuspid or bicommissural aortic valve. People who have this congenital condition are more likely to develop aortic heart valve disease.

Major Risk Factors

The major risk factors for acquired heart valve disease are:

  • Age
  • Heart disease risk factors, such as unhealthy blood cholesterol levels, high blood pressure, smoking, insulin resistance, diabetes, overweight or obesity, lack of physical activity, and a family history of early heart disease
  • Risk factors for endocarditis, such as intravenous drug use

What Are the Signs and Symptoms of Heart Valve Disease?

Major Signs and Symptoms

The main sign of heart valve disease is an unusual heart 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 of your ankles, feet, or sometimes the abdomen

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.

How Is Heart Valve Disease Diagnosed?

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

To diagnose heart valve disease, your doctor will ask about your symptoms.

He or she also will do a physical exam and look at the results of medical tests and imaging.

Physical Exam

Your doctor will listen to your heart with a stethoscope to find out if 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 keeping in water.

Tests and Procedures

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

Your doctor also may have you undergo 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.

  • Electrocardiogram (EKG)
  • Chest X Ray
  • Echocardiography
  • Transesophageal echocardiogram, or TEE
  • Cardiac Catheterization
  • Stress Test
  • Cardiac MRI

How Is Heart Valve Disease Treated?

The goals of heart valve disease treatment are to:

  • Prevent, treat, or relieve the symptoms of other related heart conditions.
  • Protect your valve from further damage.
  • Repair or replace 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 successfully treat symptoms and delay complications for many years. Eventually, though, you may need surgery to repair or replace a faulty heart valve.

Because heart valve disease may do lasting damage to your heart and can even result in sudden death, your doctor may recommend surgery, even if you are not yet showing symptoms of heart valve disease. Possible procedures are:

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 CAD. 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 for endocarditis 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 or pulmonary valves often have to be replaced.

Other Approaches for Repairing and Replacing Heart Valves

Some newer forms of heart valve repair or 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 are usually 3 to 5 days, compared to 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 effective these procedures are.

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) performed.

Living With Heart Valve Disease

Heart valve disease is a lifelong condition. However, many people with the condition don't have any symptoms until they're middle-aged or older. Over time, heart valve disease may worsen and can cause heart failure or other life-threatening conditions.

Eventually, you may need your faulty heart valve(s) repaired or replaced. After repair or replacement, you will still need certain medicines and regular checkups with your doctor.

Ongoing Health Care Needs

  • See your doctor regularly for checkups and for echocardiography or other tests. This will allow your doctor to check the progress of your heart valve disease. Ask your doctor what physical activities are appropriate for you.
  • Call your doctor if your heart valve disease symptoms worsen or you develop new symptoms.
  • Call your doctor if you develop symptoms of endocarditis. Symptoms of this heart infection include fever, chills, muscle aches, night sweats, difficulty breathing, fatigue (tiredness), weakness, red spots on the palms and soles, and swelling of the feet, legs, and belly.
  • Let your doctors and dentists know if you have a man-made valve or if you've had endocarditis before. They may give you antibiotics before medical or dental procedures (such as surgery or dental cleanings) that could allow bacteria to enter your bloodstream. Talk to your doctor about whether you need to take antibiotics before such procedures.
  • Take all your prescribed medicines.

Pregnancy and Heart Valve Disease

Mild to moderate heart valve disease during pregnancy usually can be managed with medicines or bed rest without posing heightened risks to the mother or fetus.

Most heart valve conditions can be treated with medicines that are safe to take during pregnancy. Your doctor can advise you on which medicines are safe for you.

Severe heart valve disease can make pregnancy or labor and delivery riskier. If you have severe heart valve disease and/or its symptoms, consider having your heart valves repaired or replaced before getting pregnant. Such repair or replacement also can be done during pregnancy, if needed. But this surgery poses danger to both the mother and fetus.

For more information, download and view our booklet, Heart Surgery Information for Patients and Their Families (1.7MB PDF).

Source: National Heart Lung and Blood Institute