Aortic valve disease: causes, diagnosis and treatment

What Are Heart Valve Diseases?

Heart Valve Diseases

Heart valve diseases are problems affecting one or more of the four valves in the heart. Heart valves open and shut with each heartbeat to keep blood flowing in the right direction. Problems with heart valves can occur if the valves are leaky (a condition called regurgitation), too narrow (stenosis), or don’t have a proper opening (atresia).

The causes of heart valve diseases vary from person to person. You may be born with a heart valve problem, or it may happen because of age or an infection. You may also have a heart valve problem but not experience any symptoms. Or, your symptoms may develop over time. Extreme tiredness (fatigue) is often the first symptom. You may also feel faint or lose consciousness, have  breathing difficulty or chest pain, or feel that your heart is skipping a beat, fluttering, pounding, or racing.

To diagnose a heart valve disease, your doctor may ask about your symptoms, listen to your heart, or order imaging tests to look at your heart. In newborns, screening tests can detect and help diagnose heart valve conditions.

Most heart valve conditions are treatable. Medicine may treat symptoms or prevent the condition from getting worse. Your doctor may also suggest surgery or another procedure to repair or replace a faulty heart valve. If not diagnosed and treated promptly, heart valve problems can lead to arrhythmia, infection, high blood pressure in the lungs, heart failure, or cardiac arrest.

What causes heart valve diseases?

Your heart has four valves that open and close to allow blood to flow through. Heart valve diseases develop when these valves do not work properly. Problems with your heart valves can either be present at birth or be acquired over time.

Heart valve diseases at birth

Congenital heart valve diseases develop before a baby is born, because of problems in the way the heart forms. These valve conditions can occur alone or along with other congenital heart defects.

Valve diseases seen at birth may range from mild problems to life-threatening conditions in which blood flow is blocked because no heart valve ever formed (atresia). More commonly, a valve is too narrow and does not let enough blood flow through it (stenosis). Or, valve flaps that are the wrong size or shape cause the valve to leak (regurgitation).

Some congenital heart valve diseases are inherited, which means the heart valve defect is caused by specific gene that are passed to a child from the parents. For example, bicuspid aortic valve is a type of inherited heart valve disease that can cause stenosis.

Acquired heart valve diseases

You may develop heart valve disease as you age, or because of medicine you take or a procedure you have.

Risk factors include:

  • Age: Older age can be a risk factor, especially if your lifestyle habits also raise your risk.
  • Family history: Mitral valve prolapse and bicuspid aortic valve problems can run in families. A family history of early coronary heart disease can also raise your risk of developing a heart valve disease.
  • Lifestyle habits: Risk factors for other types of heart disease may put you at risk for heart valve diseases, too. These include a lack of physical activity, unhealthy eating patterns, smoking, and obesity.
  • Medical devices: Defibrillators and pacemakers can rub against a valve and create scar tissue or stimulate the heart to beat out of rhythm, which can stretch a heart valve.
  • Other conditions: High blood pressure, diabetes,  autoimmune disorders such as lupus, and other heart conditions can raise your risk of heart valve diseases.
  • Radiation treatment for cancer can cause issues such as thickening and narrowing of heart valves.
  • Sex: At all ages, men are more likely than women to have certain heart valve conditions, such as aortic stenosis.

Types

The three types of heart valve diseases are regurgitation, stenosis, and atresia. The type of heart valve disease you have depends on which valve is affected and in what way. Heart valve diseases can cause problems in any of the heart’s four valves: the aortic, mitral, pulmonary, and tricuspid valves. For example:

  • A bicuspid aortic valve is an aortic valve that forms with two flaps instead of three.
  • Mitral valve prolapse occurs when the mitral valve flaps bulge back (prolapse) or flop into the left atrium. This may prevent the valve from forming a tight seal.
  • Pulmonary atresia and tricuspid atresia result when the pulmonary or tricuspid valve openings do not form correctly when the heart is developing.

What are heart valves?

The heart valves control blood flow through and out of the heart. When they are working well, your heart valves operate in a smooth sequence to direct blood efficiently through the heart to the lungs and rest of the body. Each valve has a set of flaps that open and close with each heartbeat. The flaps make sure blood flows in the correct direction.

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In a heart that has developed normally:

  • The aortic valve lies between the left ventricles and the aorta.
  • The mitral valve lies between the left atria and the left ventricle.
  • The pulmonary valve lies between the right ventricle and the pulmonary artery.
  • The tricuspid valve lies between the right atrium and the right ventricle.

What are the types of heart valve problems?

Atresia: Atresia is a heart condition that may be present at birth (called a congenital heart defect) or, rarely, acquired later in life. It occurs when a heart valve has no opening at all. Instead, a solid piece of tissue forms between the chambers of the heart, which blocks the flow of blood. There are two main types of heart valve atresia:

  • Pulmonary atresia affects the pulmonary valve. In this condition, blood cannot flow from the heart to the lungs through the pulmonary artery.
  • Tricuspid atresia affects the tricuspid valve. In this condition, blood cannot flow from the right atrium to the right ventricle.

Regurgitation: Regurgitation, also known as backflow or insufficiency, happens when a valve does not seal tightly. This allows blood to leak backward rather than flowing forward through the heart or into an artery. Since some blood flows in the wrong direction, your heart cannot work efficiently to get blood to your body. Regurgitation can happen if valve flaps are not the right size or shape, or if the valve opening is stretched. You may be born with heart valve regurgitation or develop it over time.

Regurgitation is most often due to prolapse in the mitral valve. This occurs when the flaps of the heart valve sag and flop back into the left atrium.

Mitral valve prolapse does not always cause backflow. In fact, most people who have mitral valve prolapse do not experience backflow and never have any related symptoms or problems. However, when backflow occurs, it can get worse over time and lead to complications such as infection and increased pressure in the heart and lungs.

Stenosis: Stenosis describes a valve opening that is too small. The valve may be too narrow, or the flaps may have formed incorrectly before birth. For example, the aortic valve may form with two flaps instead of three. This is called a bicuspid aortic valve. This condition and others that cause stenosis can make it difficult for blood to pass through the valve, so the heart has to work harder to pump enough blood to the body.

Sometimes a valve has more than one problem or more than one valve is affected. Any of these problems can make your heart work harder and affect its ability to pump blood. If a valve condition is left untreated, it can get worse over time, putting you at risk for serious problems such as heart failure or stroke.

Symptoms in newborns or young children

Signs of a heart valve condition may be present at birth. They can be seen as symptoms or may be detected during a newborn screening. Sometimes, signs of a heart valve defect may not appear until weeks or even months after birth.

Symptoms can include:

  • Not gaining weight or growing as they should: You may notice problems eating. Some children may get sweaty from the effort of eating.
  • Blue skin tone, especially the lips, fingers, and toes
  • Low levels of oxygen in the blood: Your doctor may find this using a pulse oximetry screening test.
  • Pale skin, rapid pulse or breathing, or cool, clammy hands: These are signs of shock, which is a medical emergency in newborns.
  • Weak pulse

Symptoms in adults

Symptoms of heart valve diseases that occur with older age may happen slowly. Many people mistake early signs of heart valve diseases — such as getting breathless while exercising or during typical activities — as normal signs of aging. You may also have no symptoms at all.

When symptoms of heart valve diseases occur, they can include:

  • Breathing problems, including rapid breathing or difficulty breathing, especially when climbing stairs, moving fast, or otherwise exerting yourself
  • Chest pain or discomfort, also called angina
  • Dizziness, fainting when standing up, or a short-term loss of consciousness
  • Feeling more tired than usual
  • Fever, which may signal an infection that can lead to heart inflammation (called endocarditis)
  • Feeling like your heart is beating too fast or skipping a beat
  • Heart murmur, an unusual sound that is heard between heartbeats
  • Swelling around the eyes, ankles, or abdomen
Diagnosis

Echocardiography

The echocardiogram is the most common test to diagnose a problem with the heart valves.

Echocardiography, or echo, is a painless test that uses sound waves to create moving pictures of your heart. The pictures show the size and shape of your heart and how well your heart is pumping blood. A type of echo called Doppler ultrasound shows how well blood flows through your heart’s chambers and valves.

Echo can detect blood clots inside your heart, fluid buildup in the pericardium (the sac around the heart), tumors, and problems with the aorta. The aorta is the main artery that carries oxygen-rich blood from your heart to your body. Echo also can help your doctor find the cause of abnormal heart sounds, such as heart murmurs. Your doctor also might use echo to see how well your heart responds to certain heart treatments.

Other diagnostic tests and procedures

To diagnose heart valve disease, your doctor may do other tests in addition to echocardiography.

Electrocardiogram

An electrocardiogram, also called an ECG or EKG, is a simple, painless test that detects and records your heart’s electrical activity. An EKG can show how fast your heart is beating, whether the rhythm of your heartbeats is steady or irregular, and the strength and timing of the electrical impulses passing through each part of your heart. You may have an EKG as part of a routine exam to screen for heart disease.

An EKG may be recorded in a doctor’s office, an outpatient facility, in a hospital before major surgery, or as part of stress testing. For the test, you will lie still on a table. A nurse or technician will attach up to 12 electrodes to the skin on your chest, arms, and legs. Your skin may need to be shaved to help the electrodes stick. The electrodes are connected by wires to a machine that records your heart’s electrical activity on graph paper or on a computer. After the test, the electrodes will be removed.

An EKG has no serious risks. EKGs don’t give off electrical charges such as shocks. You may develop a slight rash where the electrodes were attached to your skin. This rash usually goes away on its own without treatment.

Chest X-ray

A chest X-ray is a fast and painless imaging test to look at the structures in and around your chest. 

This test can help diagnose and check conditions such as pneumonia, heart failure, lung cancer, tuberculosis, sarcoidosis, and lung tissue scarring, called fibrosis. Doctors may use chest X-rays to see how well certain treatments are working and to check for complications after certain procedures or surgeries. 

The test may be done in the doctor’s office, clinic, or hospital. You will stand, sit, or lie still for the test.

Chest X-rays have few risks. The amount of radiation used in a chest X-ray is very small. Talk to your provider if you are or could be pregnant.

Stress test

A stress test measures how healthy your heart is and how well it works during physical stress. Some heart problems are easier to identify when your heart is working hard to pump blood throughout your body, such as when you exercise.

Your doctor may recommend this test if you have symptoms of a heart problem, such as shortness of breath, chest pain, dizziness, and a rapid or irregular heartbeat. If your doctor does find a problem, the stress test also can help your doctor choose the right treatment plan and determine what types of physical activity are safe for you.

You may do a stress test in your doctor’s office or a hospital. The test usually involves physical exercise such as walking on a treadmill or riding a stationary bicycle. If you are not able to exercise, your doctor will give you medicine that will make your heart work hard and beat faster, as if you were exercising. Your doctor may ask you not to take some of your prescription medicines or to avoid coffee, tea, or any drinks with caffeine on the day of your test, because these may affect your results. Your doctor will ask you to wear comfortable clothes and shoes for the test.

For the stress test, your doctor will put sticky patches called electrodes on your chest and attach a blood pressure cuff to your arm and a pulse monitor to your finger or other part of your body. Your doctor will measure your heart activity and blood pressure before you start the test.

You will slowly start to exercise on a treadmill or stationary bicycle, and then gradually increase the treadmill speed or bicycle resistance until your heart is working at the target heart rate for your age. Most often, a stress test includes an electrocardiogram to measure your heart’s electrical activity as you exercise. Your doctor may also measure your blood oxygen level, blood pressure, and heart rate. During the test, you will exercise for 10 to 15 minutes. Your doctor will stop the test if you show any sign of a heart problem, or if you are too tired to continue the test. If you are not able to exercise, your doctor will give you medicine over a 10- to 20-minute period through an intravenous (IV) line into one of your blood vessels.

After the stress test, your doctor will measure your heart activity and blood pressure to make sure that both measurements are back within the normal range. You should be able to return to your normal activities right away.

Screening tests

Your doctor may suggest screening tests if you have known risk factors for a heart valve disease or as part of a routine visit. Finding heart valve diseases early can lead to treatments that may prevent or fix problems. Several screening tests can identify heart valve disease.

  • Prenatal screening is used during pregnancy to check a developing baby’s heart.
  • Newborn screening tests are recommended for all newborns in the United States. One of the most common heart screening tests for newborns uses pulse oximetry to measure how much oxygen is in the baby’s blood. Low blood oxygen levels may be a symptom of dangerous heart defects. This test involves attaching sensors to the baby’s hands and feet to measure oxygen levels. Low blood oxygen levels might alert doctors to a blocked valve or valve that is not working.
  • Screening after cancer treatment is important because you may have a higher risk of developing heart valve diseases after radiation treatments.
Treatment

Heart valve disease is a lifelong condition. However, many people have heart valve defects or disease but don’t have symptoms. The condition may stay the same throughout your life and not cause any problems. Or, the condition may slowly get worse until you start to notice symptoms. If not treated, heart valve disease can cause heart failure or other life-threatening conditions.

Your healthcare provider may recommend healthy lifestyle changes or medicine first to treat symptoms, which may delay problems. Eventually, you may need to have your faulty heart valve repaired or replaced. After repair or replacement, you’ll still need certain medicines and regular checkups with your doctor.

Heart-healthy lifestyle changes

Healthy lifestyle changes include:

  • Choosing heart-healthy foods
  • Aiming for a healthy weight
  • Managing stress
  • Getting regular physical activity
  • Quitting smoking

Before starting any exercise program, ask your doctor about what level of physical activity is right for you.

Medicines

Your doctor may prescribe medicines to relieve the symptoms of your heart valve disease, prevent it from getting worse, or treat other heart problems that can affect your heart valves. These may include:

  • Medicines to control high blood pressure, such as diuretics and vasodilators, to ease pressure on the heart and reduce the amount of work the heart must do to pump blood
  • Medicines to control the heart rate
  • Blood thinners to treat or prevent blood clots
  • Antibiotics to treat infections that cause heart inflammation or prevent rheumatic fever
  • Prostaglandin for newborns to keep certain pathways of the heart open and maintain blood flow to the body
Heart valve repair

Your doctor may recommend heart valve repair if you have new symptoms of heart valve disease or your current symptoms get worse.

The various ways that heart surgeons repair heart valves are listed below. While most require surgery, some minimally invasive options are becoming available.

  • Fixing valve flaps: Surgeons may sew flaps together, reshape flaps, patch tears, reattach loose flaps, or split apart flaps that have fused. These procedures are called valvuloplasty.
  • Inflating a balloon: This allows blood to pump blood through a valve or stretch a valve opening. Valvuloplasty may also involve a balloon.
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  • Placing a stent: This allows blood to flow or plugs a leaking valve.
  • Implanting a device to treat mitral valve regurgitation: This can be used for people who should not have open-heart surgery.
  • Removing calcium deposits: Obstructions such as clumps of bacteria or tumors can also be removed.
  • Repairing supporting structures: Replacing or shortening the cords that give the valves support allow the valve to close properly.
  • Tightening or strengthening the valve base: This prevents the tissue from sagging or leaking. Surgeons may attach a plastic ring. These procedures are called annuloplasty.

Heart valve repair can improve symptoms, but sometimes problems return.

Possible complications of heart valve repairs include valve damage or leakage, blood vessel injury, cardiac compression, and stroke.

Heart valve replacement

Sometimes faulty or diseased heart valves cannot be repaired and must be replaced.

Your surgeon will replace the faulty or diseased valve with either a mechanical or a biological heart valve. Your team of doctors will work with you to determine whether a mechanical or a biological valve is best for you, depending on your age, risk factors, and other medical conditions.

  • Biological valves, also called tissue valves, are made from animal tissue and may have man-made parts as well. Although tissue valves do not require blood thinners, they do not last as long and may have to be replaced.
  • Mechanical valves are made from carbon or other sturdy material, so they last longer than biological valves and usually do not have to be replaced. However, mechanical valves require you to take blood-thinning medicines for the rest of your life. These valves may also carry additional risks during pregnancy.

Valves can be replaced during open-heart surgery or with a minimally invasive procedure using a catheter — a thin tube threaded through a blood vessel to the heart. A common example of the procedure using a catheter is transcatheter aortic valve replacement (TAVR). TAVR, which is sometimes called transcatheter aortic valve implantation (TAVI), replaces the aortic valve to treat aortic stenosis.

The risks of heart valve replacement include stroke, blood clots, damage and bleeding where the catheters were inserted, and injury to the kidneys or the heart. Sometimes the new valve leaks because it does not fit well.

How can untreated heart valve diseases affect your health?

If a heart valve disease is left untreated, it can lead to serious or life-threatening complications. Learn more about the following conditions and the symptoms to watch for:

  • Acute respiratory distress syndrome (ARDS)
  • Arrhythmias (irregular heartbeats) or other conduction disorders
  • Blood clots
  • Bloodstream infections, including septic shock
  • Expanding, bulging, or tearing of the aorta
  • Heart failure
  • Infective endocarditis, a type of heart inflammation
  • Liver damage
  • Pulmonary hypertension (high blood pressure in the lungs)
  • Stroke
  • Cardiac arrest

Source: https://www.nhlbi.nih.gov/health/heart-valve-diseases

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