Overview

Heart-valve disease is a condition in which one of the 4 valves that regulate blood-flow from and to the heart, has developed some abnormality. If detected late or left untreated, it can lead to various complications such as arrhythmias (heart-rhythm abnormalities), blood clots, stroke, heart failure and even death. Heart-valve disease is a lot more common than people think. It’s important to be aware of it, recognize the signs and symptoms and seek timely treatment.

Heart-Valves and their functioning

A valve, as one is aware, ensures liquids or gases flow in one direction only and do not flow in both directions. In the heart, impure blood collected from all over the body is oxygenated in the lungs and the oxygen-rich blood is sent to out to different parts of the body. It is important that the impure and pure blood do not mix, else the function of the heart becomes futile. Valves located inside the heart ensure a unidirectional flow of blood. There are 4 such valves:

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

Sequence of blood-flow in and out of the heart

Step 1: The left and right atrium contract once they are filled with blood. As a result, the mitral and tricuspid valves are pushed open. Blood is then pumped into the ventricles.

Step 2: The left and right ventricles contact. This closes the mitral and tricuspid valves thereby preventing blood from backing into the atria. At the same time, the aortic and pulmonic valves are pushed open and this allows blood be pumped out of the heart.

Step 3: Next, the left and right ventricles relax. The aortic and pulmonic valves close preventing blood from backing into the heart.

This if followed by step 1, thereby creating a cycle.

It is important to note that the valves are made of leaflets or pieces that together create a flap which opens and closes as required in the above sequence. While the mitral valve has 2 leaflets, the other 3 valves have 3 leaflets. The leaflets are anchored or attached firmly to the walls of the heart to withstand the high pressure of blood-flow at times, and prevent any back-flow of blood. Such reverse flow of blood is called regurgitation and can be dangerous.

Heart Valve Diseases (HVDs)

Needless to say, all the valves must be in good shape, size and performing optimally so that the heart function is not affected, and circulation is smooth. However, this is the ideal situation. There are many individuals who have one or more abnormalities, in one or more of these valves. This leads to various health conditions and complications over time.

Broadly speaking, all HVDs are of 3 types:

1. Regurgitation: The flaps of the valve don’t close properly, which causes blood to leak backwards. Also called Leaky Valve, this happens when the flaps of the valve are not flat as they should be and are instead sloping upwards, a condition called prolapse.
2. Stenosis: The flaps of the valve become thick and rigid and sometimes fuse together. This narrows down the valve-opening so there is reduced blood-flow through the valve.
3. Atresia: A congenital condition (since birth), in which the valve isn’t formed properly. Instead, a solid sheet of tissue blocks the blood-flow.

More specifically:

• Bicuspid aortic valve: The aortic valve normally has 3 leaflets, but due to a birth defect, it has only 2 leaflets in some people. Further, in some people with this defect, the valve-opening gets narrowed, so it becomes harder for the blood to flow through, because of which, some of the blood leaks backward. Symptoms do not show up until the adult years.
• Mitral valve Prolapse (also known as Barlow’s syndrome, click-murmur syndrome, balloon mitral valve, or floppy valve syndrome): In this condition, leaflets of the mitral valve prolapse and don’t close properly when the heart contracts. This causes some of the blood to leak backwards. This results in a symptom called mitral regurgitation murmur.
• Mitral valve Stenosis due to Rheumatic heart disease (RHD): RHD generally affects the mitral valve or aortic valve, but any of the valves or more than one of them can be affected. In this condition, the mitral valve opening gets narrowed down. This happens when the person has suffered from Rheumatic fever in the past. The narrowing down increases resistance to blood-flow from left atrium to left ventricle.
• Aortic valve stenosis: In this condition, the opening of the aortic valve gets narrowed down. This increases resistance to blood-flow from left ventricle to aorta.
• Pulmonary stenosis: As the name implies, the pulmonary valve does not open adequately. This causes the right ventricle to pump harder, and enlarge eventually. This is generally a congenital condition.

Also Read: Follow-up Medical care after Heart Transplant

Risk Factors for HVD

• Rheumatic fever as mentioned above. This comes from a bout of strep-throat infection that wasn’t diagnosed right or treated on time.
• An earlier episode of heart attack
• Advanced hypertension (high blood-pressure)
• Congenital problems that prevent the valves from forming properly
• The valve tissue has started degenerating or calcium deposits have started forming on the valves, thereby reducing the valve function over time
• Thoracic aortic aneurysm: A condition in which the aorta dilates or stretches unnecessarily. This in turn stretches the leaflets of the aortic valve and cause leakage
• Heart failure
• Infections in the heart such as endocarditis
• Old age (which causes weakening of the heart muscles)
• High cholesterol, diabetes and any other risk factor for cardiovascular diseases

Signs and Symptoms of HVD

• Heart murmur which sounds like a whooshing sound when the doctor is listening through a stethoscope
• Chest pain
• Shortness of breath, particularly when active or lying down
• Dizziness and fainting
• Fatigue and weakness
• Abdominal swelling and pain due to an enlarged liver
• Irregular heartbeat and hence palpitations
• Edema or swelling in the ankles and feet
• Low or high blood pressure
• Quick and unexplained weight-gain
• Infection symptoms such as fever, chills and body-ache

Diagnosis

• Electrocardiogram (ECG): This test detects arrhythmias, which can be a sign of heart muscle damage caused by an HVD.
• Echocardiogram (echo). This creates an image of the heart’s chambers and valves, which can help locate any damage to the valves
• Trans-esophageal echocardiogram (TEE): This is similar to an Echocardiogram but here the ultrasound transducer is passed through the esophagus. This creates a better image of the heart’s chambers and valves without the lungs or ribs coming in the way.
• Chest X-ray: This can show enlargement in any part of the heart, which is indicative of HVD
• Cardiac catheterization: Here, a catheter with camera attached at its end is pushed through an artery in the arm or leg, all the way to the heart. This can help detect any valve disorders.
• MRI scan: This creates a detailed image of the heart’s chambers and valves, and also its working, so that any valvular conditions can be detected quickly.

Also Read: Understanding Inherited Heart Diseases

Treatment

1. Medication

These do not cure the valvular condition but is given to relieve, control or manage symptoms better.

• Calcium-channel blockers, beta-blockers and digoxin: These are given to control heart-rate and prevent arrhythmias
• BP Medication to regulate BP: Includes diuretics that remove excess water from the body through the urine, and vasodilators that relax blood-vessels, thereby reducing volume or speed overload in the heart

2. Open-heart surgery

• Valve repair: The tissue in the abnormal valve is remodelled. Or, prosthetic rings are inserted which helps narrow down a dilated valve. In both the cases, the person’s own tissues are used, which makes it a healthy option.
• Valve replacement: When the valve damage is beyond repair, replacing the valve with a new one is the only option. The replacement may be a mechanical valve, or a biological one taken from another human being (cadaver), a cow, or a pig.

3. Non-invasive surgery

Balloon Valvuloplasty: A catheter with a deflated balloon inserted at the end is passed down an artery in the arm or leg, all the way to the narrowed-down heart valve. The balloon is then inflated which helps stretch the valve-opening, after which the balloon is deflated and the catheter pulled back.

Recovery and Rehabilitation (for open surgery)

Recovery from a valve surgery takes anywhere between 4 to 8 weeks. While leaving the hospital, the doctors will advise you on exercise to do or avoid, diet to be followed, caring for the wound (incision for surgery) and resuming a normal life. Some hospitals offer a cardiac rehabilitation program for such patients.

Dietary recommendations include consuming of lean meat, whole grains, healthy fats and low-fat dairy. Excess sugar and salt must be avoided. Alcohol consumption and smoking must be avoided in this duration. Medication will be given to ease muscle pain in the heart. Activities such as driving, sex, occupational work, gardening and housework should be minimized as far as possible.

Reviewed by Dr Suresh S Venkita, Group Medical Director, Kauvery Hospitals

NOTE: Take medications only when prescribed by your doctors, self-medication must be avoided under any circumstances.

Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai, Hosur, Salem and Bengaluru, the hospital also renders adult and pediatric trauma care.

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