Heart valve disease

Understanding heart valve disease

The heart has four valves — the mitral, aortic, tricuspid and pulmonary valves — that act as one-way doors, opening to let blood flow forward through the heart's chambers and out to the lungs and body, then closing to stop it flowing backward. Each valve opens and closes with every heartbeat, tens of thousands of times a day, for an entire lifetime. Valve disease develops when a valve stops working this way — either it narrows and does not open fully (stenosis), forcing the heart to pump harder to push blood through, or it does not close fully and lets blood leak backward (regurgitation, sometimes called incompetence). Either problem makes the heart work harder than it should, and over time that extra strain can weaken the heart muscle itself.

The aortic and mitral valves, on the left side of the heart, are affected most often because the left side does the greater share of the heart's pumping work. Valve disease can be present from birth, develop gradually with age as valve tissue thickens and stiffens, or follow an infection or inflammatory illness earlier in life. Severity, not merely the presence of a valve problem or a murmur heard on examination, is what determines how closely a valve needs to be monitored and whether it eventually needs treatment.

What heart valve disease feels like

Many people with mild valve disease have no symptoms at all, and it is found only when a clinician hears a murmur during a routine examination. When symptoms do appear, they reflect the heart working harder to compensate. These are common descriptions patients use, offered to help you put your own experience into words for a clinician — not a checklist for diagnosing yourself.

• ●Breathlessness, especially on exertion or lying flat
• ●Unusual fatigue or reduced exercise ability
• ●Palpitations, dizziness or fainting
• ●Ankle or leg swelling
• ●Chest discomfort, particularly with exertion
• ●A heart murmur noted by a clinician, sometimes with no symptoms at all

What causes heart valve disease

Valve disease has several distinct causes, and the cause often influences which valve is affected and how it is best treated.

Present from birth

Some people are born with a valve that formed slightly differently — for example, an aortic valve with two leaflets instead of the usual three — which may work normally for years before narrowing or leaking later in life.

Age-related wear

Valve tissue can thicken, stiffen and calcify with age, gradually narrowing the valve opening — the most common cause of aortic valve narrowing in later life.

Rheumatic heart disease

An untreated or inadequately treated streptococcal throat infection in childhood can trigger rheumatic fever, an inflammatory illness that can scar and damage heart valves, usually the mitral valve, sometimes not becoming apparent until years later. Rheumatic heart disease remains an important and preventable cause of valve disease in Nigeria, which is why prompt treatment of childhood sore throats matters.

Infection of the valve (infective endocarditis)

Bacteria can occasionally settle on a heart valve, particularly one already abnormal, causing infection that damages the valve directly and can be serious if not treated promptly.

Other causes

An enlarged, stretched heart from any cause — including cardiomyopathy or longstanding high blood pressure — can pull a normal valve out of shape, causing it to leak even though the valve tissue itself is not diseased.

Who is more likely to develop heart valve disease

These factors are worth mentioning at your appointment:

• ●A history of rheumatic fever or frequent untreated childhood sore throats
• ●Increasing age
• ●A valve condition present from birth, or a family history of one
• ●High blood pressure and other conditions that enlarge the heart
• ●Chronic kidney disease
• ●Poor dental health or dental disease, which raises the risk of valve infection
• ●A previous episode of infective endocarditis

What happens if valve disease goes untreated

Many valve problems are mild and simply monitored; more significant disease carries real risks if left unaddressed.

Heart failure. The extra work of pumping against a narrowed valve, or the inefficiency of pumping through a leaking one, can gradually weaken the heart muscle.

Atrial fibrillation. An enlarged upper heart chamber, often a consequence of mitral valve disease, can trigger this irregular rhythm, which itself raises stroke risk.

Stroke. Blood can pool and clot in an enlarged, poorly emptying heart chamber; a clot that breaks free can travel to the brain.

Valve infection. A damaged valve is more vulnerable to infective endocarditis, which can cause further, sometimes rapid, valve destruction.

Pulmonary hypertension. Longstanding left-sided valve disease can raise pressure in the lung circulation, adding further strain on the heart.

How Cardiocare finds the cause

The right pathway depends on your symptoms, examination and overall health. It typically draws on some or all of the following:

• 01
  Clinical examination. Listening for a murmur, its timing and location can already suggest which valve is affected and how.
• 02
  Echocardiogram with Doppler. A painless ultrasound scan that shows each valve's structure, how well it opens and closes, and measures the severity of narrowing or leakage — the central test for valve disease.
• 03
  12-lead ECG. A painless recording of the heart's electrical activity, which can show strain on a particular chamber or an irregular rhythm.
• 04
  Chest X-ray. Can show heart enlargement or fluid in the lungs when relevant.
• 05
  Transoesophageal echocardiography. For a closer view of certain valves, particularly before some procedures.
• 06
  Blood tests. Including markers of heart strain and, when infection is suspected, blood cultures.
• 07
  Heart-team review. For significant valve disease, cardiologists and cardiac surgeons jointly consider the best timing and type of treatment.

How heart valve disease is treated

Treatment depends on which valve is affected, whether it is narrowed or leaking, how severe the problem is, and your symptoms — many people need only regular monitoring for years before any procedure is considered.

Watchful waiting

Mild to moderate valve disease with no symptoms is often simply monitored with regular clinical review and echocardiograms, watching for any change in severity or the start of symptoms.

Medicines, by class

Medicines cannot repair a damaged valve, but they help manage its effects and related conditions:

• ●Diuretics — help clear excess fluid when the heart is under strain
• ●ACE inhibitors or ARBs, and beta blockers — support heart function and reduce workload where indicated
• ●Anticoagulants (blood thinners) — needed for atrial fibrillation associated with valve disease, and for anyone with a mechanical replacement valve
• ●Antibiotics — used to treat infective endocarditis when it occurs, and sometimes given before certain dental or surgical procedures in people at particular risk

Procedures

Available through Cardiocare's cardiac surgery service and cath lab, for significant valve disease causing symptoms or affecting heart function:

• ●Valve repair — a surgeon reshapes and reinforces the patient's own valve where the tissue allows it, often preferred when possible
• ●Valve replacement — the damaged valve is replaced with a mechanical or tissue valve; see our heart valve surgery guide

Living with valve disease: everyday self-care

Most people with valve disease live full, active lives, especially with regular follow-up:

• ✓Attend regular echocardiogram follow-up, even if you feel completely well
• ✓Maintain good dental hygiene and treat dental problems promptly — the mouth is a common source of the bacteria that cause valve infection
• ✓Tell every clinician and dentist you see about your valve condition before any procedure
• ✓Report any new breathlessness, reduced exercise capacity or fever without delay
• ✓Discuss pregnancy or planned major surgery with your cardiology team beforehand
• ✓If you have a mechanical valve, take your blood thinner exactly as prescribed and keep monitoring appointments

Preparing for your appointment

What to bring

• ✓A list of all medicines you take, including herbal and over-the-counter preparations
• ✓Any previous echocardiogram reports, ECGs or hospital letters
• ✓Your HMO card or payment details and a valid means of identification

What we will ask

Your symptoms and how they affect daily activity, any history of childhood rheumatic fever or frequent sore throats, and any family history of valve disease.

Questions worth asking us

• ●Which valve is affected, and how severe is it?
• ●Do I need a procedure now, or can this be monitored?
• ●How often will I need follow-up echocardiograms?
• ●Are there precautions I should take before dental or other procedures?