Valvular Heart Disease

Types of Valvular Problems

• Stenosis: The valve doesn't open fully, restricting blood flow. The heart has to pump harder to force blood through the narrowed opening.
• Regurgitation (Insufficiency or Leakage): The valve doesn't close properly, causing blood to leak backward (regurgitate) with each heartbeat. This means the heart pumps the same blood twice and has to work harder.
• Prolapse: A condition where the valve leaflets (flaps) bulge backward into an upper heart chamber during heart contraction. Most commonly affects the mitral valve (mitral valve prolapse), often benign but can lead to regurgitation.

Causes

• Congenital Heart Defects:
  • Some individuals are born with abnormally formed heart valves (e.g., bicuspid aortic valve, where the aortic valve has two leaflets instead of the usual three). These defects may not cause problems until adulthood.
• Degenerative Valve Disease (Aging):
  • The most common cause in developed countries, especially for aortic stenosis and mitral regurgitation.
  • Over time, wear and tear, calcium buildup, and fibrous thickening can stiffen and narrow the valves (stenosis) or make them leaky (regurgitation).
• Rheumatic Fever:
  • A complication of untreated strep throat. It can cause permanent damage to heart valves, particularly the mitral and aortic valves, leading to rheumatic heart disease. This is a common cause in developing countries.
• Infective Endocarditis:
  • A serious infection of the heart's inner lining and valves, usually caused by bacteria entering the bloodstream.
  • Can damage and perforate valve leaflets, leading to severe regurgitation.
• Coronary Artery Disease (CAD) and Heart Attack:
  • Reduced blood flow or damage to the heart muscle (e.g., from a heart attack) can affect the structures supporting the mitral valve, leading to mitral regurgitation.
• Cardiomyopathy:
  • Enlargement of the heart chambers (especially in dilated cardiomyopathy) can stretch the valve annulus (the ring around the valve), causing the valves (often mitral or tricuspid) to leak.
• High Blood Pressure (Hypertension): Long-standing uncontrolled high blood pressure can contribute to valve wear and tear.
• Syphilis: (Rare) Can affect the aortic valve.
• Radiation Therapy: Radiation to the chest (e.g., for cancer) can cause valve damage years later.

Symptoms

• Shortness of Breath (Dyspnea): Especially with exertion, when lying flat (orthopnea), or waking up at night with shortness of breath (paroxysmal nocturnal dyspnea).
• Fatigue and Weakness: Feeling tired, even with mild activity.
• Chest Pain or Discomfort: Especially with aortic stenosis.
• Dizziness or Lightheadedness, Fainting (Syncope): Particularly with aortic stenosis or significant arrhythmias.
• Heart Palpitations: Sensations of a rapid, pounding, or irregular heartbeat.
• Swelling (Edema): In the ankles, feet, or abdomen (ascites) due to fluid retention (especially with tricuspid or pulmonary valve issues, or severe heart failure).
• Swelling of the Abdomen (Ascites).
• Rapid Weight Gain: Due to fluid retention.
• Cough: Especially at night, due to fluid in the lungs.
• Difficulty Concentrating or Memory Problems.
• Heart Murmur: An abnormal whooshing or swishing sound heard with a stethoscope during a physical exam. This is often the first sign detected by a doctor.

Diagnosis

• Medical History and Physical Exam: The doctor will ask about symptoms, risk factors, and family history. Key findings include heart murmurs, abnormal heart sounds, signs of fluid overload, or arrhythmias.
• Electrocardiogram (ECG/EKG): Records the heart's electrical activity. Can show signs of heart enlargement, strain, or abnormal rhythms.
• Chest X-ray: Can show an enlarged heart or signs of fluid buildup in the lungs.
• Echocardiogram (Echo):
  • Transthoracic Echocardiogram (TTE): The most common and essential diagnostic test. Uses sound waves to create moving images of the heart valves and chambers. It directly visualizes valve structure, assesses opening and closing, measures blood flow (Doppler), and estimates valve area and regurgitation severity.
  • Transesophageal Echocardiogram (TEE): A more detailed echo where a probe is guided down the throat, providing clearer images of the valves (especially useful for pre-surgical planning or endocarditis).
• Cardiac Catheterization:
  • An invasive procedure where catheters are threaded into the heart chambers to directly measure pressures and sometimes assess valve function. Also used to check for coronary artery disease.
  • Less commonly used for initial diagnosis of valve disease due to excellent echocardiography, but important for surgical planning.
• Cardiac MRI (Magnetic Resonance Imaging): Provides detailed images of heart structure and function, including valve morphology and blood flow dynamics, often used for more complex cases or when echo is inconclusive.
• Stress Test: To assess how symptoms develop during physical activity and how valve function changes under stress.

Treatment

• Watchful Waiting: For mild or asymptomatic valve disease, regular monitoring with echocardiograms is typically recommended.
• Medications:
  • Diuretics ("Water Pills"): To reduce fluid retention and swelling.
  • Beta-Blockers or Calcium Channel Blockers: To control heart rate and rhythm, and manage blood pressure.
  • ACE Inhibitors or ARBs (Angiotensin Receptor Blockers): To reduce blood pressure and ease the heart's workload.
  • Anticoagulants (Blood Thinners): (e.g., warfarin, DOACs) To prevent blood clots, especially for patients with artificial heart valves, atrial fibrillation, or a history of clots.
  • Antibiotics: To treat infective endocarditis, or sometimes as prophylaxis for certain dental/medical procedures in high-risk patients (guidelines have become more restrictive).
• Lifestyle Modifications:
  • Sodium Restriction: To manage fluid retention.
  • Healthy Diet.
  • Regular Exercise: As tolerated and advised by a doctor.
  • Blood Pressure and Cholesterol Control.
  • Quit Smoking.
• Surgical and Minimally Invasive Procedures:
  • Valve Repair:
    • Whenever possible, repairing a valve is preferred over replacement.
    • Techniques include annuloplasty (tightening the valve ring), commissurotomy (opening fused leaflets), or leaflet repair.
  • Valve Replacement:
    • The diseased valve is removed and replaced with either a mechanical valve (durable, requires lifelong anticoagulation) or a biological/tissue valve (less durable, usually doesn't require lifelong anticoagulation).
  • Transcatheter Aortic Valve Replacement (TAVR) / Transcatheter Aortic Valve Implantation (TAVI):
    • A minimally invasive procedure for aortic stenosis, where a new valve is delivered via a catheter (usually through an artery in the leg) and expanded into place without open-heart surgery.
    • Primarily for older or high-risk patients.
  • Transcatheter Mitral Valve Repair (e.g., MitraClip): A minimally invasive procedure for mitral regurgitation, where a clip is used to bring the valve leaflets closer together.

Living With a Valve Problem

Most valve disease is found as a murmur years before it needs anything done, and the work in between is monitoring at the right interval, protecting the valve from infection, and recognizing the symptoms that mean the timing has changed, so intervention happens when it helps most.

Echo intervals and why they matter

Surveillance echocardiograms are spaced by severity, from every few years for mild disease to yearly or more for severe, and the interval is reset at each result. The purpose is to catch the point at which the heart chamber begins to enlarge or weaken, which can precede symptoms and is itself a reason to intervene; skipping a scheduled echo is the most common way that window is missed. Our cardiovascular team keeps the schedule between cardiology visits.

Symptoms change the timing

In severe aortic stenosis, breathlessness on exertion, chest pressure, or a fainting spell moves intervention to a near-term plan, because outcomes decline quickly once symptoms begin. New swelling, waking short of breath, or falling exercise tolerance is reported rather than attributed to age; our early signs of heart failure article covers what to watch for. Fainting with a known valve problem is evaluated the same day.

Blood thinners depend on the valve

A mechanical valve requires warfarin for life, and newer anticoagulants such as apixaban are not substitutes for it. With a tissue or repaired valve, apixaban is acceptable when atrial fibrillation develops, which it often does as the atrium stretches; rheumatic mitral stenosis with atrial fibrillation is the other case where warfarin remains standard. Our atrial fibrillation article explains the rhythm side.

Protecting the valve from infection

Antibiotics before dental work are recommended only for the highest-risk group: prosthetic valves or repair material, a prior episode of endocarditis, and certain congenital conditions. For everyone else the protection is daily dental hygiene and regular cleanings, because most endocarditis follows bacteria entering from the mouth over time rather than from a single procedure. A fever lasting more than a few days with a valve problem is evaluated with blood cultures before antibiotics.

Blood pressure, exercise, and after a procedure

Controlling blood pressure reduces the load on a leaking valve, and lisinopril is typical; furosemide treats fluid buildup but does not change the valve. Moderate exercise is encouraged, with limits on heavy straining set individually for severe stenosis. After valve surgery or a transcatheter procedure, cardiac rehabilitation and a follow-up echo set the new baseline; our hospital discharge follow-up article covers the first weeks home. Coronary artery disease is assessed before any valve intervention because the two are often treated together. NHLBI and MedlinePlus publish patient guidance on valve disease and its treatment.

If you were told you have a murmur or valve problem and have not had an echocardiogram in the past few years, schedule a visit.