Valvular heart disease

What is valvular heart disease?

The heart has four chambers. The two upper chambers are called the left and right atrium, and the two lower chambers are called the left and right ventricle. The four valves at the exit of each chamber maintain one-way continuous flow of blood through the heart to the lungs and the rest of the body.

The four valves are the tricuspid valve, pulmonary valve, mitral valve and aortic valve.

• Oxygen-poor blood coming into your heart from your body flows into the right atrium. The tricuspid valve is the valve between the right atrium and the right ventricle. It opens so blood can be pumped to the right ventricle.
• The pulmonary valve controls blood flow between the right ventricle and the lungs. It opens to let the heart pumps blood out of the ventricles into the pulmonary artery toward the lungs so it can pick up oxygen. The oxygen-rich blood flows back from the lungs into the left atrium.
• The mitral valve lies between the left atrium and the left ventricle. It opens so the oxygen-rich blood from the left atrium can be pumped into the left ventricle.
• The aortic valve controls blood flow from the left ventricle into the aorta (the main artery in your body). When this valve opens, the oxygen-rich blood is pumped to the aorta and then out to fuel the rest of your body.

In between each step, the valve closes to prevent blood from flowing backwards and mixing oxygen-poor blood with oxygen-rich blood. The one-way continuous flow of blood delivers oxygen throughout your body.

Heart valve disease occurs when one or more of the heart valves do not open or close properly. When it affects more than one heart valve, it is called multiple valvular heart disease.

• Stenosis is when the valve opening becomes narrow and restricts blood flow.
• Prolapse is when a valve slips out of place or the valve flaps (leaflets) do not close properly.
• Regurgitation is when blood leaks backward through a valve, sometimes due to prolapse.

Heart valve disease can be classified as mild, moderate or severe. It can lead to an enlarged heart or heart failure. Heart failure is a serious medical condition where the heart cannot pump enough blood to meet the body’s need for oxygen.

Many valvular heart diseases can be treated with medication, or surgery and other procedures to repair or replace the valve.

Types of valvular heart disease

1. Valvular stenosis (narrowing)

The stiffening of heart valves can narrow the size of the valve opening and restrict blood flow. The narrowing is called valve stenosis. It keeps the valve from opening fully and reduces the amount of blood that can flow through. In severe cases, the valve opening can become so narrow that the rest of the body may not receive adequate blood flow.

• Tricuspid valve stenosis If your tricuspid valve narrows, blood is not able to fully move from the right atrium to the right ventricle. This can cause the atrium to enlarge, affecting pressure and blood flow in the surrounding chambers and veins. It can also cause the right ventricle to become smaller, so less blood circulates to your lungs to pick up oxygen.
• Pulmonary valve stenosis If your pulmonary valve narrows, the flow of oxygen-poor blood from the right ventricle through the pulmonary arteries to the lungs is restricted. This affects your blood’s ability to pick up oxygen and deliver oxygen-rich blood to the rest of your body. With pulmonary valve stenosis, the right ventricle has to work harder to pump blood through the narrowed pulmonary valve and the pressure in the heart is often increased.
• Mitral valve stenosis When the mitral valve narrows, blood flow from the left atrium to the left ventricle is reduced. This can cause fatigue and shortness of breath because the volume of blood carrying oxygen from the lungs is reduced. Pressure from the blood that has stayed in the left atrium can cause the atrium to enlarge and fluid to build up in the lungs.
• Aortic valve stenosis When the aortic valve narrows, blood flow from your heart to your aorta (the main artery to your body) and onwards to the rest of your body is restricted. As a result, the left ventricle has to contract harder to try push blood across the aortic valve. This can often lead to thickening of the left ventricle (left vernacular hypertrophy) which eventually makes the heart less efficient.

2. Valvular prolapse (slipping out of place)

Prolapse is a condition when the valve flaps (leaflets) slip out of place or form a bulge. This can lead to improper or uneven closure of the heart valve. As a result of the prolapsed valve, blood may leak backwards through the valve and one-way blood flow may be disrupted.

• Mitral valve prolapse In mitral valve prolapse, the valve fails to close evenly. Part or all of the mitral valve bulges upward into the atrium when the two ventricles contracts. This can allow a small amount of blood to leak backward through the valve (regurgitation). Mitral valve prolapse is also called click-murmur syndrome, Barlow’s syndrome or floppy valve syndrome.
• Tricuspid, pulmonary and aortic valve prolapse These prolapses are less common than mitral valve prolapse. Similar to mitral valve prolapse, the leaflets of the valve do not close completely and fail to form a tight seal.

3. Regurgitation (leaking)

Regurgitation can happen when the valve doesn’t close properly and allows blood to flow backwards. This disruption of the one-way blood flow in the heart puts a strain on your heart, reduces its pumping efficiency and limits its ability to supply your body with oxygen-rich blood.

• Tricuspid valve regurgitation When the tricuspid valve does not close properly, blood that is being pumped forward from the right ventricle to the lungs can leak backward into the right atrium, and the atrium may become enlarged.
• Pulmonary valve regurgitation This results when the pulmonary valve doesn’t close properly. The lower right chamber (right ventricle) of the heart pushes blood through the pulmonary artery into the lungs for blood to pick up oxygen. When the pulmonary valve does not close completely, blood can leak back from the lungs into the heart. This backward blood flow mixes oxygen-poor and oxygen-rich blood, and reduces the availability of oxygen-rich blood to fuel the rest of your body.
• Mitral valve regurgitation In mitral valve regurgitation, some blood leaks backward into the left atrium through the mitral valve from the lower chamber as it contracts. This reduces the amount of blood that flows to the rest of the body. As a result of regurgitation, the blood volume and pressure are increased in the left atrium. In severe cases, the increase in volume and pressure may lead to enlargement of the atrium and build-up of fluid (congestion) in the lungs.
• Aortic valve regurgitation This results when oxygen-rich blood leaks backward from the aorta into the left ventricle with each heartbeat. Your body does not get enough blood and the heart has to work harder to make up for it. Over time the walls of the ventricle may thicken (hypertrophy). This can increase your risk of heart failure.

Causes

Valvular heart disease can develop before or at birth (congenital causes) or normal valves may become damaged during one’s lifetime (acquired causes). The cause of valvular heart disease is not always known. Support for more research into the causes of valvular heart disease is needed.

1. Congenital causes

• Congenital valvular heart disease This is a birth defect that may involve a heart valve being the wrong size or the wrong shape, or its valve flaps (leaflets) not being properly attached to the heart.
• Bicuspid aortic valve disease A congenital defect that affects the aortic valve. Instead of the normal three leaflets, the bicuspid aortic valve has only two leaflets. Without the third leaflet, the valve is unable to open or close properly, is more prone to aortic valve stenosis, and may lead to regurgitation.
• Marfan syndrome This is a genetic disorder that affects the body’s connective tissue. Connective tissue holds all the body’s cells, organs and tissues together, including in the heart. People with Marfan syndrome may develop mitral valve prolapse and aortic valve regurgitation.

2. Acquired causes

• Rheumatic fever This is an inflammatory disease that can affect the heart valves if it isn’t treated properly. Rheumatic fever usually starts as strep throat or an infection involving strep (streptococcal bacteria). Heart valves may be damaged or scarred as the body fights the strep infection.
• Infective (bacterial) endocarditis Common germs can travel through the bloodstream to the heart and infect the surface of the heart, including the heart valves. People with valvular heart disease are at a higher risk of developing infective endocarditis.
• Radiation therapy People who had radiation therapy to the chest due to cancer are more likely to develop valvular heart disease.
• Age Heart valve problems may result from degenerative changes, or normal “wear and tear” of aging.

3. Other causes

• coronary artery disease
• damage to the heart muscle from a heart attack
• other diseases of the heart muscle (cardiomyopathy)
• metabolic disorders such as high blood cholesterol
• tumour in the heart
• certain medications.

Symptoms 

Many people do not notice any symptoms until their blood flow has been significantly reduced by valvular heart disease. Symptoms can include:

• Chest discomfort, pressure or tightness (angina) along the front of your body between your neck and upper abdomen.
• Palpitations (irregular or rapid heartbeats caused by problems with the heart's electrical system) can sometimes be a symptom of valvular heart disease. Your heart may be working harder. That can cause your heart to enlarge and affect normal heart rhythm, leading to arrhythmia.
• Shortness of breath – especially when you are active. Valvular heart disease reduces the amount of oxygen available to fuel your body and that causes breathlessness.
• Fatigue or weakness. You may find it harder to do routine activities such as walking or housework.
• Light-headedness, dizziness or near fainting is most common with aortic stenosis.
• Swelling can occur when valve problems cause blood to back up in other parts of the body, leading to fluid buildup and swollen abdomen, feet and ankles.

If you don’t have many symptoms or if they are mild and not affecting you too much, your doctor may choose to monitor your condition carefully and wait until it is necessary to treat your symptoms. It is important to understand that the symptoms of valvular heart disease may not necessarily reflect the seriousness of the problem. Be sure to have regular check-ups and discuss any changes in your health that you notice with your doctor.

Women are more prone than men to valvular heart disease caused by rheumatic fever. Women should be especially careful about any strep infection (streptococcal bacteria).

Women with a history of heart disease should consult their doctor if they are planning a pregnancy. Pregnancy is often associated with significant changes in blood flow and blood pressure and that can aggravate valvular heart disease and increase the risk of an adverse cardiac event.

Diagnosis

A diagnosis of valvular heart disease usually begins with the symptoms you report to your healthcare team and the results of a physical exam. During the exam, your doctor will listen to your heart with a stethoscope. An unusual sound called a heart murmur can be heard through the stethoscope. A heart murmur doesn’t always mean that you have a heart problem because people with normal hearts may also have murmurs.

Your doctor will listen to your lungs to check for fluid buildup. They will also look for swelling in your abdomen, feet and ankles.
Test for valvular heart disease also include:

• echocardiogram
• angiogram
• chest X-ray
• electrocardiogram (ECG)
• stress test
• heart MRI.

Treatment

Treatment depends on the severity of your valvular heart disease. If your heart valve problem is very minor you may not need any treatment at all. You will have regular check-ups to see if your condition gets any worse.

Medication can be prescribed if your heart valve problem is causing symptoms.

If your condition is more serious, you may need more intensive treatment. Options include valve repair or replacement in combination with medication. The approach taken will depend on your age, your general health, which valve is affected, and the type and severity of your condition.

You and your doctor will discuss the treatment options and decide which is best for you and your circumstances.

1. Medication

Medication cannot cure valvular heart disease, but it may relieve swelling, abnormal heart rhythm, high blood pressure and other symptoms.

Your doctor may prescribe:

• Diuretics (water pills) to reduce swelling and fluid buildup in the body.
• Blood thinners to prevent blood clots and reduce the risk of other cardiac problems.
• Antiarrythmics to prevent irregular or rapid heartbeats (arrhythmias).

If you have a heart condition in addition to valvular heart disease (such as coronary heart disease or heart failure), you may be prescribed medications to reduce the workload on your heart and relieve your symptoms. 

2. Surgeries and other procedures

Heart valve surgery to repair or replace your heart valves may be necessary to prevent lasting damage to your heart.

Valve repair

• Heart valves may be repaired by patching holes or tears, reshaping the valve, or separating valve leaflets so that they can open and close properly
• Valve stenosis may be opened by inserting a thin catheter with a balloon at the tip through a blood vessel to the narrowed valve. The balloon is then inflated to widen the valve opening. This procedure is called balloon valvulopasty.
• Annuloplasty is a technique to repair an enlarged annulus (a ring of fibrous issue at the base of the heart valve). Sutures are sewn around the ring to make the opening smaller. Or a ring-like device is attached around the outside of the valve opening so that it can close more tightly.

Valve replacement

If a faulty heart valve cannot be repaired, it is removed and replaced with a mechanical valve or a biological valve. You and your doctor will discuss the options and decide which is best for you and your circumstances.

• Mechanical valves are made from durable metals, carbon, ceramics and plastics.
• Biological valves are made from animal tissue, donated human tissue, or a patient’s own tissues. Biological valves are not as durable as mechanical valves.

An alternative to open-heart surgery to replace a malfunctioning aortic valve is a less invasive procedure called transcatheter aortic valve implantation (TAVI or TAVR). A replacement valve is inserted through a catheter that is guided to your heart with the ultrasound and chest x-rays.

3. Lifestyle

You can lower your risk of developing other heart diseases and stroke by knowing and controlling your blood pressure, diabetes and blood cholesterol. It’s also important to lead a healthy lifestyle. 

• Be smoke-free.
• Be more active.
• Aim for a healthy weight.
• Eat a healthy balanced diet – there are some specific diets you can follow that have been proven to reduce the risk of heart disease.
• Drink less alcohol.
• Manage stress.

Talk to your doctor about the lifestyle changes that will benefit you the most.

Living with valvular heart disease 

Many people who have valvular heart disease lead full lives. Here are some things to be aware of as you learn to live with your heart condition.

• Valvular heart disease can increase your risk of developing heart failure where your heart muscle isn’t strong enough to pump enough blood through your body. That’s why it is important to be aware of your symptoms and report any changes in your health to your healthcare team.
• You may be at a higher risk for infective endocarditis. Be sure to talk to your dentist or doctor if you need dental work, have your teeth cleaned or are undergoing any medical procedures involving your respiratory system (for example bronchoscopy, tonsillectomy or adenoidectomy). You may need to take antibiotics before and after these procedures.
• Vaccines to prevent flu and pneumonia are another proactive way to stay healthy. Many people with  chronic heart problems are less able to fight infections. You might be more susceptible to respiratory tract infections that can lead to serious complications and even death. Talk to your doctor about the flu vaccine.
• Women’s and men’s hearts are different – which leads to differences in their treatment and care. This is especially true for women who are planning to start a family. Be sure to discuss your options with your doctor.
• Cardiac rehab is a personalised program of exercise, education and counselling to help you recover from heart valve disease. Rehab will help you regain your strength and reduce your risk of having other heart problems in the future. Talk to your doctor about how to find a program in your area or contact your public health department or hospital. The Canadian Association of Cardiac Rehabilitation also has a cardiac rehabilitation program directory to help you find a program in your community.

Related information 

Manage your medications

Read Jennifer Michaud’s experience with aortic stenosis and the research that could provide alternative treatment to surgery. 

Some people with serious valvular heart disease and heart failure find that palliative and end-of-life care provide comfort to them and their family. Learn more about end-of-life care.

Watch our valvular heart disease webinar to hear researchers and people living with the disease discuss its causes, symptoms and treatment.  

Heart valve disease guide (Peter Munk Cardiac Centre)

Special thanks Updates to this health information content are made possible through an unrestricted educational grant from Edwards Lifesciences (Canada) Inc. This publication has been independently researched, written and reviewed by Heart & Stroke. Edwards Lifesciences (Canada) Inc has no direct influence over any aspect of the content and educational activities funded by this grant.
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