Valvular Heart Disease

How heart valves work

The heart has four valves that keep blood moving forward:

• tricuspid valve: between the right atrium and right ventricle
• pulmonary valve: from the right ventricle to the lungs
• mitral valve: between the left atrium and left ventricle
• aortic valve: from the left ventricle to the body

Each valve opens to let blood through and closes to prevent backflow. Problems on the left side (aortic and mitral) are more common and usually more serious.

Types of valve disease

Common valve conditions

• Aortic stenosis: the most common valve disease needing treatment in older adults. Usually from calcium buildup after age 65, or earlier with a bicuspid aortic valve.
• Mitral regurgitation: from degeneration, mitral valve prolapse, or an enlarged heart after a heart attack or cardiomyopathy.
• Aortic regurgitation: from a bicuspid valve, an enlarged aorta, or endocarditis.
• Mitral stenosis: usually from rheumatic heart disease, common worldwide but less so in the US.
• Tricuspid regurgitation: often secondary to lung disease, atrial fibrillation or left-sided valve disease.

Causes and risk factors

• age-related degeneration and calcification
• congenital defects: bicuspid aortic valve (about 1 to 2 in 100 people)
• rheumatic fever after untreated strep throat
• endocarditis: infection of the valve
• heart attack or cardiomyopathy stretching the valve ring
• high blood pressure, high cholesterol, diabetes, kidney disease and smoking
• radiation to the chest
• some medicines and connective tissue disorders such as Marfan syndrome

Symptoms

Valve disease can be silent for years. Symptoms usually develop gradually:

• shortness of breath, especially with exertion or lying flat
• tiredness and reduced exercise tolerance
• chest pain or pressure on exertion (especially aortic stenosis)
• dizziness or fainting (especially aortic stenosis)
• palpitations or irregular heartbeat, often atrial fibrillation
• swollen ankles, feet or belly
• rapid weight gain from fluid

The start of symptoms with severe valve disease, especially aortic stenosis, is an important turning point and usually means treatment is needed.

Diagnosis

• listening with a stethoscope: most valve disease causes a heart murmur
• echocardiogram: the key test, showing valve structure, how narrowed or leaky it is, and heart function
• ECG: heart rhythm and strain
• chest X-ray
• transesophageal echocardiogram for detailed images before repair or when endocarditis is suspected
• cardiac CT or MRI and cardiac catheterization before procedures
• exercise testing to uncover symptoms in people who report none

Treatment

Monitoring

Mild to moderate disease without symptoms is monitored with regular echocardiograms, every 1 to 5 years depending on severity.

Medicines

Medicines do not fix the valve but can control symptoms and related problems:

• diuretics for fluid buildup
• blood pressure and heart failure medicines
• rate or rhythm control and blood thinners for atrial fibrillation
• antibiotics to prevent rheumatic fever recurrence in people with rheumatic heart disease

Repair or replacement

• Surgical valve repair: preferred for many mitral regurgitation cases, preserving the patient's own valve
• Surgical valve replacement: with a mechanical valve (long-lasting, requires lifelong warfarin) or a biological tissue valve (no long-term warfarin, may wear out after 10 to 20 years)
• Transcatheter aortic valve replacement (TAVR): a new valve placed through a catheter, usually from the groin, without open-heart surgery. Now widely used for aortic stenosis across many risk groups
• Transcatheter edge-to-edge repair (TEER): a clip that reduces mitral or tricuspid leakage
• Balloon valvuloplasty: for some cases of mitral or pulmonary stenosis

The choice depends on age, valve type, other illnesses and personal preferences, decided with a heart team.

Living with valve disease

• keep regular follow-up and echocardiograms
• report new symptoms promptly
• maintain good dental hygiene and regular dental checkups
• people with artificial valves or previous endocarditis may need antibiotics before certain dental procedures
• stay active within your doctor's advice
• control blood pressure, cholesterol and diabetes, and do not smoke
• people on warfarin need regular INR checks

Frequently asked questions

What are the symptoms of heart valve disease?

Common symptoms are shortness of breath, tiredness, chest pain or pressure, dizziness or fainting, palpitations and swollen ankles. Many people have no symptoms for years, and the condition is found when a doctor hears a murmur.

What is the most common heart valve disease?

Aortic stenosis is the most common valve disease needing treatment in older adults, mainly from age-related calcium buildup. Mitral regurgitation is also very common.

Can a heart valve heal on its own?

No. Damaged heart valves do not repair themselves. Mild disease may stay stable for years with monitoring. Significant disease is treated with valve repair or replacement, which often restores normal life expectancy.

What is TAVR?

TAVR, or transcatheter aortic valve replacement, is a procedure in which a new aortic valve is placed through a catheter, usually inserted in the groin, without opening the chest. Recovery is usually faster than with open-heart surgery.

Is valvular heart disease serious?

It can be. Severe valve disease that causes symptoms can lead to heart failure, arrhythmias, stroke and sudden death if untreated. With timely monitoring and treatment, most people do well.