Heart Valve Disease

Heart valves allow for proper blood flow within the heart and the arteries throughout the body. The four heart valves each work as one-way valves to move blood while preventing backflow of blood into one of the heart's four chambers. When the heart beats (contracts), the valves open and close in alternating fashion to pump blood through the two atria upper chambers and two ventricles, the lower chambers. The four types of heart valves are:

• Tricuspid valve: Between the right atrium and right ventricle
• Pulmonary valve: Between the right ventricle and pulmonary artery
• Mitral valve: Between the left atrium and left ventricle
• Aortic valve: Between the left ventricle and aorta

Heart valve disease can be caused by a variety of factors, including genetic conditions, degeneration, infections or other medical conditions. As adults age, they become more likely to suffer valvular heart disease, but heart valve disease in young adults is also possible with a genetic condition or an increase in risk factors. Studies show men may develop heart valve disease at a younger age than women.

Risk factors for heart valve damage vary according to the type of disease and may include one or more of the following:

• Heart attack
• Infection
• Aging
• Congenital birth defect
• Syphilis
• Myxomatous degeneration, an inherited connective tissue disorder
• History of rheumatic fever

The cause for individual cases of heart valve disease is not always known and is not always preventable. The best chance at preventing valvular heart disease or mitigating symptoms comes from reducing risk factors and creating a healthy lifestyle. Lifestyle changes may include:

• Not smoking and limiting alcohol consumption
• Eating a heart-healthy diet
• Engaging in regular exercise
• Controlling high blood pressure and high cholesterol

Each individual may experience heart valve disease symptoms differently, and mild heart valve disease may not cause any symptoms.

The following are the most common symptoms of heart valve disease:

• Chest pain
• Palpitations caused by irregular heartbeats
• Fatigue
• Dizziness
• Low blood pressure
• Shortness of breath
• Abdominal pain due to an enlarged liver (if there is tricuspid valve malfunction)

Heart valve disease symptoms may resemble other medical conditions and problems. Always consult a doctor for evaluation and diagnosis.

Valvular heart disease can happen to any of the four heart valves, but the mitral valve is the one most often impacted by heart disease problems. Common heart valve disease issues:

• Mitral valve prolapse: Considered the top culprit for heart valve disease, mitral valve prolapse leads to a leaky mitral valve, allowing mitral regurgitation, where blood flows back into the left atrium from the left ventricle and increases pressure in the left atrium.
• Mitral valve stenosis: Another common issue stems from the mitral valve. When there's a narrowing of the valve, blood flow is restricted from the left atrium to the left ventricle. This issue forces the left atrium to overwork and can cause congestion in the lungs and potential failure of the right ventricle.
• Aortic stenosis: The narrowing of the aortic valve limits blood from the left ventricle to the aorta, forcing the left ventricle to work harder to pump blood throughout the body, potentially leading to a thickening of the left ventricle.
• Aortic regurgitation: A leakage of the aortic valve sends blood leaking into the ventricle from the aorta, worsening pressure on the left ventricle and causing lung congestion.

At Brigham and Women’s Hospital, our heart valve disease specialists provide expert evaluation and diagnosis with the aid of the latest in advanced imaging technologies. To most efficiently diagnose and determine treatment for valve disease, a complete medical history, a thorough physical exam, and one or more of the special diagnostic tests below may be provided.

• Cardiac catheterization
• Chest X-ray
• Cardiac ultrasound (echocardiography)
• Electrocardiogram

Treatment for heart valve disease aims to protect your valve and heart from additional damage while reducing symptoms caused by valvular heart disease. Early treatment options may include medication and lifestyle changes, but often surgery is necessary to repair or replace the damaged valve or valves. Valve surgery involves two major categories—valve replacement and valve repair.

Medical experts will help decide the best treatment course based on the type of valve disease, severity of valve damage and a patient's age and medical history.

Pre-Surgery Treatment Options

Doctors may prescribe both medications and lifestyle changes to alleviate symptoms before the need for heart valve surgery. Doctors may also want time to monitor the heart valve before deciding on repair or replacement. Medications used include beta blockers to control heart rate and blood pressure medications to reduce the heart's workload.

Repair of Valves with Valvular Heart Disease

A repair of a diseased heart valve repair aims to fix the valve without a full replacement. A valve repair procedure often comes with a lower level of after-surgery monitoring and medication because the procedures are commonly less invasive with the use of catheters. A valve repair may include sculpting abnormal valve tissue to improve the function of the valve, patching holes, separating fused valve leaflets, replacing supportive cords or removing excess tissue. Surgeons may use clips or plugs and could add a ring to reinforce the valve.

Valve replacement involves removing the native valve and replacing it with an artificial valve made of either mechanical parts or biological tissues. The choice between a mechanical valve and a biological valve is based on many factors, including:

• Patient preference
• Age
• Overall health
• Medical history
• Severity and form of the disease
• Tolerance for specific medications or procedures
• Expectations for course of the disease
• Presence of other conditions

A heart valve replacement may involve a biological (from animal tissue), mechanical, or homograft (from a human cadaver donor) prosthesis. Types of prosthetic valves used in valve replacement include:

• Mechanical valves­: Made of graphite and pyrolytic carbon, or other synthetic materials, which are non-reactive and tolerated well in the human body. While designed to last as long as 30 years, mechanical valves require lifelong blood thinning medications to avoid blood clots forming on the valve, which can cause stroke and other complications. Because of the need for lifelong blood thinning medications, patients with a mechanical valve carry a higher risk of bleeding complications following surgery.
• Biologic (tissue) valves: Made from animal tissue (pig or cow) or a donated human heart. The animal tissue valves are sterilized and chemically treated for human use and then sewn onto a frame (stented) or left intact (stentless). These types of valves last approximately 10-20 years or longer, depending on the age of the patient at the time of implant. An additional replacement, therefore, isn’t uncommon in younger patients. Long-term blood-thinning medications are not required following valve replacement with biological valves, but may be needed in the first four to six weeks following the surgery.
• Homograft: Available from a human cadaver donor.

Surgeons at Brigham and Women’s Hospital will walk you through this decision process, the expected outcomes, and address any and all concerns throughout your pre-operative assessment.

There are a variety of techniques that are used to repair or replace valves:

• Aortic valve replacement—treats narrowing and/or leakage of the aortic valve.
• Root-enlarging procedure—effective in smaller aortic valves
• Aortic root replacement—used in connective tissue disorders, large aortic root aneurysms, endocarditis or aortic dissections
• Valve-sparing root surgery—usually used for young patients with intact aortic valves and isolated disease of the aortic root who wish to avoid blood-thinning medications
• Stented biological aortic valve replacement
• Stentless biological aortic valve replacement
• Homograft mitral valve surgery—typically performed for mitral valve disease. Leaflet repair through patching of holes or tears in the valve leaflets and/or by reconstructing leaflets to rebuild the native valve
• Ring annuloplasty—a ring attached to the tissue around the valve, to provide the support needed for the valve to close tightly
• Tricuspid valve surgery—which includes a variety of techniques, is used to treat leakage and safely repair tricuspid valve disorders

Open heart surgery, which involves opening the chest with a nine-inch incision and cutting through the sternum (sternotomy), has long been the standard approach for any of the valve replacement procedures described above.

Our heart valve specialists also offer several minimally invasive valve replacement procedures that are designed to result in less trauma, less blood loss, less pain and a shorter hospital stay:

• Upper mini-sternotomy—for this technique, a small (three-inch) incision is made in the chest, and much of the sternum remains intact. Minimally invasive surgery can be then performed through this incision six cm in length
• Minimally invasive mitral valve surgery can be performed through a lower sternotomy
• Transcatheter aortic valve replacement (TAVR)
• Other interventional cardiology procedures:
  • Percutaneous mitral valvuloplasty, or widening of the valve
  • Percutaneous aortic valvuloplasty
  • MitraClip