What is valve disease and how is it treated?

Heart valve disease is when one or more of the four valves inside the heart does not open or close properly. A valve that has become narrowed and stiff, known as stenosis, restricts blood flow out of a chamber. A valve that does not seal, known as regurgitation or a leaky valve, lets blood flow backwards. Either way the heart has to work harder, and over time that can lead to breathlessness, chest pain, dizziness and eventually heart failure.

Treatment depends on which valve is affected and how severe the problem is. Mild valve disease usually needs nothing more than regular monitoring with an ultrasound scan. When a valve becomes severely narrowed or leaky, it is usually repaired or replaced, either through open heart surgery or, increasingly, through a keyhole procedure carried out via an artery in the leg. Medicines can ease symptoms but cannot fix a faulty valve.

How the heart valves work

The heart has four valves that keep blood moving in one direction. The tricuspid and pulmonary valves sit on the right side of the heart, which pumps blood to the lungs. The mitral and aortic valves sit on the left side, which pumps blood around the body. Because the left side works at much higher pressure, the mitral and aortic valves are the ones most likely to cause problems. The British Heart Foundation notes that these two valves are the most commonly affected.

The most common types of valve disease

Aortic stenosis. This is the valve problem I see most often. The aortic valve gradually thickens and calcifies with age, so it opens less fully and the heart has to push harder to force blood through it. It is most common in people over 70. In younger adults, it is often linked to a bicuspid aortic valve, where the valve is born with two leaflets instead of three. This affects around 1 to 2 in every 100 people, and many do not find out until a murmur is heard in middle age.

Mitral regurgitation. The mitral valve fails to close properly and blood leaks backwards into the left atrium with each beat. It can be caused by a floppy valve, known as mitral valve prolapse, or by the heart chamber enlarging and stretching the valve open. It is often associated with atrial fibrillation.

Aortic regurgitation. A leaky aortic valve lets blood fall back into the main pumping chamber. It is sometimes linked to a bicuspid valve or to widening of the aorta.

Mitral stenosis. Narrowing of the mitral valve was once common because of rheumatic fever in childhood. It is much rarer in the UK now, but I still see it in patients who grew up in countries where rheumatic fever remains common.

Symptoms of heart valve disease

Many people with valve disease have no symptoms for years. The first sign is often a heart murmur heard by a GP during a routine examination, and a murmur is one of the most common reasons I am asked to see a patient.

As valve disease progresses, symptoms can include the following.

• Breathlessness on exertion, and later at rest or when lying flat.
• Chest tightness or pain on exertion.
• Dizziness or fainting, particularly during physical activity.
• Palpitations, which may be a sign of atrial fibrillation.
• Swollen ankles and fatigue.

Fainting during exercise is a particularly important symptom in aortic stenosis and should always be assessed promptly. Blackouts can have many causes, but this pattern is one that cardiologists take very seriously.

From working with patients over many years, I've found that symptoms of valve disease are easy to miss because they come on so slowly. People adapt without realising it. They stop taking the stairs, walk more slowly or give up a sport, and put it down to getting older. When I ask what someone could do two years ago compared with now, the change is often much clearer than they had appreciated.

How valve disease is diagnosed

The main test is an echocardiogram. It shows the structure of each valve, measures how narrowed or leaky it is, and assesses how well the heart muscle is coping with the extra workload. It is painless, takes around 20 to 40 minutes and needs no preparation. What happens during an echocardiogram is straightforward, and most patients are surprised by how quickly it is over.

Echocardiography has been a particular focus of my career, and I perform both standard transthoracic echocardiograms and transoesophageal echocardiograms. A transoesophageal echo uses a small probe passed down the gullet under sedation, which sits just behind the heart and gives much clearer pictures of the valves. It is especially helpful when planning mitral valve repair or when a valve infection is suspected.

Other tests may include an ECG to check the rhythm, a CT scan to measure the aortic valve and aorta before a keyhole procedure, and a coronary angiogram to check the heart arteries before valve surgery. You can find more about each of these on my heart tests page.

Monitoring mild and moderate valve disease

Most people with mild valve disease need no treatment, only regular review. The BHF explains that mild disease is often monitored with an echocardiogram every three to five years, while moderate or severe disease is usually checked every six to twelve months.

In my experience, regular echocardiogram surveillance works better than waiting for symptoms because the heart muscle can begin to strain before a patient feels any different. Picking up early enlargement or weakening of the heart on a scan allows treatment to be timed before permanent damage occurs, which tends to give better long-term results after surgery.

For patients with severe aortic stenosis who say they have no symptoms, I sometimes use an exercise test. It can reveal breathlessness, a fall in blood pressure or ECG changes that the patient has not noticed in daily life, and that can change the decision about when to operate.

How heart valve disease is treated

Medicines. Diuretics can ease breathlessness and swelling, and other medicines can control blood pressure, slow the heart rate or prevent blood clots if atrial fibrillation develops. These help with symptoms and protect the heart, but they cannot reverse the narrowing or leak in the valve itself.

Surgical valve replacement. For many years, open heart surgery to replace the aortic valve has been the standard treatment for severe aortic stenosis. Replacement valves are either mechanical, which last a lifetime but require blood thinning medication for life, or tissue valves, which usually avoid long-term anticoagulation but may wear out after many years.

TAVI. Transcatheter aortic valve implantation replaces the aortic valve using a catheter passed up from an artery in the groin, without opening the chest. It was first used for patients too frail for surgery, but it is now offered to a much wider group. Recovery is usually quick, and many people go home within a few days.

Valve repair. A leaking mitral valve can often be repaired rather than replaced, preserving the patient's own valve. For some people who are not suitable for surgery, the leak can be reduced with a clip delivered by catheter through a vein in the leg.

The right choice depends on age, overall health, the anatomy of the valve and the patient's own preferences. These decisions are usually made by a heart team of cardiologists and cardiac surgeons, and I make sure patients understand the options and feel part of that discussion.

Protecting your valves

Some valve problems are present from birth and others develop with age, so not all can be prevented. There are, however, a few things that help.

• Keep your teeth and gums healthy and see a dentist regularly, because bacteria from the mouth are a common cause of endocarditis, an infection of the heart valves.
• Control your blood pressure, which reduces strain on the aortic valve and aorta.
• Seek medical advice about a fever that does not settle if you have a known valve problem or a replacement valve.
• Keep follow-up appointments, even when you feel well.

When to get a murmur or valve problem checked

If you have been told you have a heart murmur, or you are noticing breathlessness, chest discomfort or dizziness on exertion, a specialist assessment with an echocardiogram will show whether a valve is involved and how significant it is. In over 20 years as a Consultant Cardiologist at Kingston Hospital NHS Trust, I've found that most murmurs turn out to be harmless or mild, and the reassurance of knowing that is valuable in itself.

Please contact me, Dr Arvind Vasudeva, if you would like your heart valves checked. I see patients at Parkside Hospital in Wimbledon, The New Victoria Hospital in Kingston, Cleveland Clinic London and Heartsure in Kingston, and you can book an appointment at the location that suits you best.