Heart valve disease

Heart valves

Heart valve disease occurs if one or more of your heart valves don't work well. 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

Figure 1 shows the location of the heart in the body. Figure B shows a cross-section of a healthy heart and its inside structures. The blue arrow shows the direction in which oxygen-poor blood flows through the heart to the lungs. The red arrow shows the direction in which oxygen-rich blood flows from the lungs into the heart and then out to 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 lungs fills the atria (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 atria, these valves open to allow blood to flow into the ventricles (the heart's two lower chambers).

After a brief delay, as the ventricles begin to contract, the mitral and tricuspid valves shut tightly. This prevents blood from flowing back into the atria.

As the ventricles contract, they pump blood through the pulmonary and aortic valves. The pulmonary valve opens to allow blood to flow from the right ventricle 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 ventricle into the aorta. The aorta carries oxygen-rich blood to the body. As the ventricles relax, the pulmonary and aortic valves shut tightly. This prevents blood from flowing back into the ventricles.

For more information about how the heart pumps blood and detailed animations, go to the Health Topics How the Heart Works article.

Heart Valve Problems

Heart valves can have three basic kinds of problems: regurgitation, stenosis, and atresia.

Regurgitation, or backflow, occurs if a valve doesn't close tightly. Blood leaks back into the chambers rather than flowing forward through the heart or into an artery.

In the United States, backflow most often is 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.

Stenosis occurs if the flaps of a valve thicken, stiffen, or fuse together. This prevents the heart valve from fully opening. As a result, not enough blood flows through the valve. Some valves can have both stenosis and backflow problems.

Atresia occurs if a heart valve lacks an opening for blood to pass through.

Some people are born with heart valve disease, while others acquire it later in life. Heart valve disease that develops before birth is called congenital heart valve disease. Congenital heart valve disease can occur alone or with other congenital heart defects.

Congenital heart valve disease often 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 aortic or mitral valves. Although the valves are normal at first, problems 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 mostly stays the same throughout their lives and doesn't cause any problems.

For other people, heart valve disease slowly worsens until symptoms develop. If not treated, advanced heart valve disease can cause heart failure, stroke, blood clots, or death due to sudden cardiac arrest (SCA).

Currently, no medicines can cure heart valve disease. However, lifestyle changes and medicines can relieve many of its symptoms and complications.  

These treatments also can lower your risk of developing a life-threatening condition, such as stroke or SCA. 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, childhood, or even before birth. Other types may not cause problems until middle-age or older, if at all.

Other Names- 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

Causes- Heart Valve Disease

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

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

Heart Conditions and Other Disorders

Certain conditions can stretch and distort the heart valves. These conditions include:

• Advanced high blood pressure and heart failure, this can enlarge the heart or the main arteries.
• Atherosclerosis in the aorta. Atherosclerosis is a condition in which a waxy substance called plaque builds up inside the arteries. The aorta is the main artery that carries oxygen-rich blood to the body.
• Damage and scar tissue due to a heart attack or injury to the heart.

Rheumatic Fever

Untreated strep throat or other infections with strep bacteria that progress to rheumatic fever can cause heart valve disease.

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 most often are affected. Symptoms of heart valve damage often don’t appear until many years after recovery from rheumatic fever.

Today, most people who have strep infections are treated with antibiotics before rheumatic fever occurs. If you have strep throat, take all of the antibiotics your doctor prescribes, even if you feel better before the medicine is gone.

Heart valve disease caused by rheumatic fever mainly affects older adults 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 the bloodstream and get carried to the heart can sometimes infect the inner surface of the heart, including the heart valves. This rare but serious infection is called infective endocarditis.

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

Infective endocarditis can develop in people who already have abnormal blood flow through a heart valve as the result of 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.

Infective endocarditis can worsen existing heart valve disease.

Other Conditions and Factors Linked to Heart Valve Disease

Many other conditions and factors are linked to heart valve disease. However, the role they play in causing heart valve disease often isn’t clear.

• Autoimmune disorders. Autoimmune disorders, such as lupus, 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.
• Diet medicines. The use of fenfluramine and phentermine (“fen-phen”) sometimes has been linked to heart valve problems. These problems typically stabilize or improve after the medicine is stopped.
• Marfan syndrome. Congenital disorders, such as Marfan syndrome and other connective tissue disorders, can affect the heart valves.
• Metabolic disorders. Relatively uncommon diseases (such as Fabry disease) and other metabolic disorders (such as high blood cholesterol) can affect the heart valves.
• 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 until years after the therapy.

Risk Factors- Heart Valve Disease

Older age is a risk factor for heart valve disease. As you age, your heart valves thicken and become stiffer. Also, people are living longer now than in the past. As a result, heart valve disease has become an increasing problem.

People who have a history of infective endocarditis (IE), rheumatic fever, heart attack, or heart failure—or previous heart valve disease—also are at higher risk for heart valve disease. In addition, having risk factors for IE, such as intravenous drug use, increases the risk of heart valve disease.

You're also at higher risk for heart valve disease if you have risk factors for coronary heart disease. These risk factors include high blood cholesterol, high blood pressure, smoking, insulin resistance, diabetes, overweight or obesity, lack of physical activity, and a family history of early heart disease.

Some 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.

Screening and Prevention- Heart Valve Disease

To prevent heart valve disease caused by rheumatic fever, see your doctor if you have signs of a strep infection. These signs include a painful sore throat, fever, and white spots on your tonsils. If you do have a strep infection, be sure to take all medicines prescribed to treat it. Prompt treatment of strep infections can prevent rheumatic fever, which damages the heart valves.

It’s possible that exercise, a heart-healthy diet, and medicines that lower cholesterol might prevent aortic stenosis (thickening and stiffening of the aortic valve). Researchers continue to study this possibility.

Heart-healthy eating, physical activity, other heart-healthy lifestyle changes, and medicines aimed at preventing a heart attack, high blood pressure, or heart failure also may help prevent heart valve disease.

Major Signs and Symptoms

The main sign of heart valve disease is an unusual heartbeat 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 occur 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 cause. These signs and symptoms include:

• Unusual fatigue (tiredness)
• Shortness of breath, especially when you exert yourself or when you're lying down
• Swelling in your ankles, feet, legs, abdomen, and veins in the neck

Other Signs and Symptoms

Heart valve disease can cause chest pain that may happen only 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.

Diagnosis- Heart Valve Disease

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

To diagnose heart valve disease, your doctor will ask about your signs and symptoms. He or she also will do a physical exam and look at the results from tests and procedures.

Physical Exam

Your doctor will listen to your heart with a stethoscope. He or she will want to find out whether 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 retaining water.

Tests and Procedures

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

Your doctor also may recommend other tests and procedures if you're diagnosed with heart valve disease. For example, you may have cardiac catheterization, (KATH-eh-ter-ih-ZA-shun), stress testing, or cardiac MRI (magnetic resonance imaging). These tests and procedures help your doctor assess how severe your condition is so he or she can plan your treatment.

EKG

This simple test detects and records the heart's electrical activity. An EKG can detect an irregular heartbeat and signs of a previous heart attack. It also can show whether your heart chambers are enlarged.

An EKG usually is done in a doctor's office.

Chest X Ray

This test can show whether certain sections of your heart are enlarged, whether you have fluid in your lungs, or whether calcium deposits are present in your heart.

A chest x ray helps your doctor learn which type of valve defect you have, how severe it is, and whether you have any other heart problems.

Echocardiography

Echo uses sound waves to create a moving picture of your heart as it beats. A device called a transducer is placed on the surface of your chest.

The transducer sends sound waves through your chest wall to your heart. Echoes from the sound waves are converted into pictures of your heart on a computer screen.

Echo can show:

• The size and shape of your heart valves and chambers
• How well your heart is pumping blood
• Whether a valve is narrow or has backflow

Your doctor may recommend transesophageal (tranz-ih-sof-uh-JEE-ul) echo, or TEE, to get a better image of your heart.

During TEE, the transducer is attached to the end of a flexible tube. The tube is guided down your throat and into your esophagus (the passage leading from your mouth to your stomach). From there, your doctor can get detailed pictures of your heart.

You'll likely be given medicine to help you relax during this procedure.

Cardiac Catheterization

For this procedure, a long, thin, flexible tube called a catheter is put into a blood vessel in your arm, groin (upper thigh), or neck and threaded to your heart. Your doctor uses x-ray images to guide the catheter.

Through the catheter, your doctor does diagnostic tests and imaging that show whether backflow is occurring through a valve and how fully the valve opens. You'll be given medicine to help you relax, but you will be awake during the procedure.

Your doctor may recommend cardiac catheterization if your signs and symptoms of heart valve disease aren't in line with your echo results.

The procedure also can help your doctor assess whether your symptoms are due to specific valve problems or coronary heart disease. All of this information helps your doctor decide the best way to treat you.

Stress Test

During stress testing, you exercise to make your heart work hard and beat fast while heart tests and imaging are done. If you can't exercise, you may be given medicine to raise your heart rate.

A stress test can show whether you have signs and symptoms of heart valve disease when your heart is working hard. It can help your doctor assess the severity of your heart valve disease.

Cardiac MRI

Cardiac MRI uses a powerful magnet and radio waves to make detailed images of your heart. A cardiac MRI image can confirm information about valve defects or provide more detailed information.

This information can help your doctor plan your treatment. An MRI also may be done before heart valve surgery to help your surgeon plan for the surgery.

Treatment- Heart Valve Disease

Currently, no medicines can cure heart valve disease. However, lifestyle changes and medicines often can treat symptoms successfully and delay problems for many years. Eventually, though, you may need surgery to repair or replace a faulty heart valve.

The goals of treating heart valve disease might include:

• Medicines
• Repairing or replacing faulty valves
• Heart-healthy lifestyle changes to treat other related heart conditions

Medicines

In addition to heart-healthy lifestyle changes, your doctor may prescribe medicines to:

• Lower high blood pressure or high blood cholesterol.
• Prevent arrhythmias (irregular heartbeats).
• Thin the blood and prevent clots (if you have a man-made replacement valve). Doctors also prescribe these medicines for mitral stenosis or other valve defects that raise the risk of blood clots.
• Treat coronary heart disease. Medicines for coronary heart disease can reduce your heart’s workload and relieve symptoms.
• Treat heart failure. Heart failure medicines widen blood vessels and rid the body of excess fluid.

Repairing or Replacing Heart Valves

Your doctor may recommend repairing or replacing your heart valve(s), even if your heart valve disease isn’t causing symptoms. Repairing or replacing a valve can prevent lasting damage to your heart and sudden death.

The decision to repair or replace heart valves depends on many factors, including:

• The severity of your valve disease
• Whether you need heart surgery for other conditions, such as bypass surgery to treat coronary heart disease. Bypass surgery and valve surgery can be performed at the same time.
• Your age and general health

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 of infective 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 and pulmonary valves often have to be replaced.

Repairing Heart Valves

Heart surgeons can repair heart valves by:

• Adding tissue to patch holes or tears or to increase the support at the base of the valve
• Removing or reshaping tissue so the valve can close tighter
• Separating fused valve flaps

Sometimes cardiologists repair heart valves using cardiac catheterization. Although catheter procedures are less invasive than surgery, they may not work as well for some patients. Work with your doctor to decide whether repair is appropriate. If so, your doctor can advise you on the best procedure.

Heart valves that cannot open fully (stenosis) can be repaired with surgery or with a less invasive catheter procedure called balloon valvuloplasty. This procedure also is called balloon valvotomy.

During the procedure, a catheter (thin tube) with a balloon at its tip is threaded through a blood vessel to the faulty valve in your heart. The balloon is inflated to help widen the opening of the valve. Your doctor then deflates the balloon and removes both it and the tube. You’re awake during the procedure, which usually requires an overnight stay in a hospital.

Balloon valvuloplasty relieves many symptoms of heart valve disease, but may not cure it. The condition can worsen over time. You still may need medicines to treat symptoms or surgery to repair or replace the faulty valve. Balloon valvuloplasty has a shorter recovery time than surgery. The procedure may work as well as surgery for some patients who have mitral valve stenosis. For these people, balloon valvuloplasty often is preferred over surgical repair or replacement.

Balloon valvuloplasty doesn’t work as well as surgery for adults who have aortic valve stenosis. Doctors often use balloon valvuloplasty to repair valve stenosis in infants and children.

Replacing Heart Valves

Sometimes heart valves can’t be repaired and must be replaced. This surgery involves removing the faulty valve and replacing it with a man-made or biological valve.

Biological valves are made from pig, cow, or human heart tissue and may have man-made parts as well. These valves are specially treated, so you won’t need medicines to stop your body from rejecting the valve.

Man-made valves last longer than biological valves and usually don’t have to be replaced. Biological valves usually have to be replaced after about 10 years, although newer ones may last 15 years or longer. Unlike biological valves, however, man-made valves require you to take blood-thinning medicines for the rest of your life. These medicines prevent blood clots from forming on the valve. Blood clots can cause a heart attack or stroke. Man-made valves also raise your risk of infective endocarditis.

You and your doctor will decide together whether you should have a man-made or biological replacement valve.

If you’re a woman of childbearing age or if you’re athletic, you may prefer a biological valve so you don’t have to take blood-thinning medicines. If you’re elderly, you also may prefer a biological valve, as it will likely last for the rest of your life.

Ross Procedure

Doctors also can treat faulty aortic valves with the Ross procedure. During this surgery, your doctor removes your faulty aortic valve and replaces it with your pulmonary valve. Your 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 procedure 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 well within a few years of the surgery. Researchers continue to study the use of this procedure.

Other Approaches for Repairing and Replacing Heart Valves

Some forms of heart valve repair and 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 usually are 3 to 5 days, compared with a 5-day stay 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.

TRANSCATHETER VALVE THERAPY

Interventional cardiologists perform procedures that involve threading clips or other devices to repair faulty heart valves using a catheter (tube) inserted through a large blood vessel. The clips or devices are used to reshape the valves and stop the backflow of blood. People who receive these clips recover more easily than people who have surgery. However, the clips may not treat backflow as well as surgery.

Doctors also may use a catheter to replace faulty aortic valves. This procedure is called transcatheter aortic valve replacement (TAVR). For this procedure, the catheter usually is inserted into an artery in the groin (upper thigh) and threaded to the heart. A deflated balloon with a folded replacement valve around it is at the end of the catheter.

Once the replacement valve is placed properly, the balloon is used to expand the new valve so it fits securely within the old valve. The balloon is then deflated, and the balloon and catheter are removed.

A replacement valve also can be inserted in an existing replacement valve that is failing. This is called a valve-in-valve procedure.

Heart-Healthy Lifestyle Changes to Treat Other Related Heart Conditions

To help treat heart conditions related to heart valve disease, your doctor may advise you to make heart-healthy lifestyle changes, such as:

• Heart-healthy eating
• Aiming for a healthy weight
• Managing stress
• Physical activity
• Quitting smoking

Living With

Heart valve disease is a lifelong condition. However, many people have heart valve defects or disease but don’t have symptoms. For some people, the condition mostly stays the same throughout their lives and doesn’t cause any problems.

For other people, the condition slowly worsens until symptoms develop. If not treated, advanced heart valve disease can cause heart failure or other life-threatening conditions.

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

Ongoing Care

If you have heart valve disease, 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.

Call your doctor if your symptoms worsen or you have new symptoms. Also, discuss with your doctor whether heart-healthy lifestyle changes might benefit you. Ask him or her which types of physical activity are safe for you.

Call your doctor if you have symptoms of infective endocarditis (IE). Symptoms of this heart infection include fever, chills, muscle aches, night sweats, problems breathing, fatigue (tiredness), weakness, red spots on the palms and soles, and swelling of the feet, legs, and belly.

Take all of your medicines as prescribed.

Pregnancy and Heart Valve Disease

Mild or moderate heart valve disease during pregnancy usually can be managed with medicines or bed rest. With proper care, the disease usually won’t pose heightened risks to the mother or fetus.

Doctors can treat most heart valve conditions 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 risky. If you have severe heart valve disease, consider having your heart valves repaired or replaced before getting pregnant. This treatment also can be done during pregnancy, if needed. However, this surgery poses danger to both the mother and fetus.

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