Aortic Valve Disease

How the aortic valve works

The aortic valve usually has three thin leaflets (cusps). It opens with each heartbeat to let blood flow from the left ventricle into the aorta, then closes to stop it flowing back. Valve problems force the left ventricle to work harder. At first it compensates by thickening (in stenosis) or enlarging (in regurgitation), but eventually it weakens and heart failure develops.

Types of aortic valve disease

See aortic stenosis and aortic valve regurgitation for each in detail.

Causes

Calcific (degenerative) disease

The most common cause of aortic stenosis in older adults. Calcium deposits build up on the leaflets over decades, stiffening them. Risk factors overlap with heart disease: age, high blood pressure, high cholesterol, smoking, diabetes and kidney disease.

Bicuspid aortic valve

About 1% to 2% of people are born with only two leaflets. Bicuspid valves wear out earlier, often causing stenosis in the 50s and 60s, or regurgitation in younger adults. They are associated with a widened or weakened aorta (aortic aneurysm) and run in families.

Rheumatic heart disease

After rheumatic fever from untreated strep throat, scarring can damage the aortic and mitral valves. It is now uncommon in the US but remains a major cause worldwide.

Other causes

• Infective endocarditis: infection can destroy leaflets and cause sudden severe regurgitation.
• Aortic root dilation: from long-standing high blood pressure, Marfan syndrome or other connective tissue disorders.
• Aortic dissection: a tear in the aorta can cause acute regurgitation.
• Radiation to the chest.

Symptoms

Mild and moderate disease usually causes no symptoms. As disease becomes severe:

• shortness of breath, first with exertion, later at rest or lying down
• chest pain or tightness with activity (angina)
• dizziness, lightheadedness or fainting, especially during exercise
• tiredness and reduced exercise tolerance
• palpitations or a pounding heartbeat (more in regurgitation)
• ankle swelling in advanced heart failure

Many older people put reduced activity down to aging, which can delay diagnosis.

Diagnosis

1. Listening to the heart: a murmur is often the first clue.
2. Echocardiogram: shows the valve structure, the severity of narrowing or leakage, and how well the heart is pumping. Severe aortic stenosis is generally defined by a valve area under 1.0 cm² or a high pressure gradient.
3. ECG: may show thickening of the heart muscle or rhythm problems.
4. Exercise testing: to uncover symptoms in people who say they have none.
5. CT scan: measures valve calcium, the aorta, and plans TAVR.
6. Cardiac catheterization: checks the coronary arteries before valve replacement.
7. Blood tests: BNP as a marker of heart strain.

Treatment

Monitoring

People with mild or moderate disease without symptoms have regular echocardiograms, usually every 1 to 5 years depending on severity. Control blood pressure, cholesterol and other heart risk factors. No medicine slows calcific stenosis.

Medicines

Medicines relieve symptoms but do not fix the valve:

• diuretics for fluid build-up
• blood pressure medicines, especially for regurgitation
• treatment of rhythm problems

Valve replacement

Replacement is recommended for severe disease with symptoms, a weakening or enlarging left ventricle, or in some cases severe disease even without symptoms.

• Transcatheter aortic valve replacement (TAVR): a new valve is delivered through an artery, usually in the groin, and expanded inside the old valve. Recovery is quick, often going home in 1 to 2 days. It is now used across all risk levels in older adults with stenosis.
• Surgical aortic valve replacement (SAVR): open-heart surgery to replace the valve, preferred for younger patients, bicuspid valves with aortic enlargement, regurgitation, or when other heart surgery is needed.
• Valve repair: possible for some leaking valves.
• Ross procedure: the patient's own pulmonary valve is moved to the aortic position, mainly in young adults.

Choosing a valve

• Mechanical valves last a lifetime but require lifelong warfarin.
• Tissue (biological) valves do not need long-term anticoagulation but wear out over 10 to 20 years.

Complications

• heart failure
• arrhythmias, including atrial fibrillation
• sudden cardiac death in severe untreated stenosis
• infective endocarditis
• bleeding from the gut (Heyde syndrome) in some people with stenosis

Living with aortic valve disease

• Report new symptoms promptly; the appearance of symptoms changes the plan.
• Ask your cardiologist which exercise is safe. People with severe stenosis should avoid strenuous or competitive sports.
• Keep good dental hygiene to reduce endocarditis risk; people with replacement valves usually need antibiotics before some dental procedures.
• Women with significant valve disease should get specialist advice before pregnancy.

Frequently asked questions

What are the symptoms of aortic valve disease?

Early disease usually causes no symptoms. Severe disease causes breathlessness on exertion, chest pain, dizziness or fainting, tiredness and palpitations. Symptoms often develop gradually and may be mistaken for aging.

What causes aortic valve disease?

In older adults, the most common cause is calcium build-up on the valve with age. A bicuspid aortic valve, present from birth, is the most common cause in younger adults. Rheumatic fever, endocarditis and a widened aorta are other causes.

What is the life expectancy with aortic stenosis?

Without valve replacement, survival falls sharply once symptoms appear, with many people living only a few years. After successful TAVR or surgery, life expectancy in many people returns close to that of others their age.

Is TAVR better than open-heart surgery?

Both are effective. TAVR is less invasive with faster recovery and is often preferred for older adults with aortic stenosis. Open surgery is often preferred for younger people, bicuspid valves with an enlarged aorta, leaking valves, or when other heart surgery is needed.

Can aortic valve disease be prevented?

Not entirely, but controlling blood pressure and cholesterol, not smoking and managing diabetes may slow calcific disease. Treating strep throat promptly prevents rheumatic fever. Good dental care lowers the risk of endocarditis.