Valvular Heart Disease
Valvular heart disease occurs when one or more of the heart’s valves do not open or close properly, affecting how blood flows through the heart.
Some valve problems are mild and may only require regular monitoring. Others can place additional strain on the heart and may eventually cause symptoms such as shortness of breath, fatigue, chest discomfort or swelling of the legs.
The appropriate management depends on which heart valve is affected, the type and severity of the valve problem, whether symptoms are present, and how the condition is affecting heart function.
What Is Valvular Heart Disease?
The heart has four valves:
- Aortic valve
- Mitral valve
- Tricuspid valve
- Pulmonary valve
These valves open and close as the heart beats, helping blood move in the correct direction through the heart and into the circulation.
Valvular heart disease generally occurs in two main ways:
Valve stenosis occurs when a valve becomes narrowed and does not open fully. The heart may need to work harder to pump blood through the narrowed opening.
Valve regurgitation, sometimes called valve insufficiency or a leaking heart valve, occurs when a valve does not close properly, allowing some blood to flow backwards.
A person may have stenosis, regurgitation or a combination of both.
Which Heart Valves Are Commonly Affected?
Heart valve disease can affect any of the four valves, although the specific causes and effects vary depending on the valve involved.
Aortic Valve Disease
The aortic valve controls blood flow from the heart’s main pumping chamber, the left ventricle, into the aorta.
Aortic stenosis occurs when the valve becomes narrowed. As the narrowing becomes more significant, the heart has to generate greater pressure to pump blood through the valve.
Aortic regurgitation occurs when the valve does not close completely and blood leaks backwards into the left ventricle.
Mitral Valve Disease
The mitral valve is located between the left atrium and left ventricle.
Mitral stenosis restricts the flow of blood between these chambers.
Mitral regurgitation allows blood to leak backwards into the left atrium when the left ventricle contracts.
Some people may also have mitral valve prolapse, where part of the valve bulges backwards during a heartbeat. This does not always cause significant regurgitation or require treatment.
Tricuspid and Pulmonary Valve Disease
Conditions affecting the tricuspid or pulmonary valves may also cause stenosis or regurgitation.
The clinical significance depends on the underlying cause, severity of the valve abnormality and its effect on the heart.
What Causes Valvular Heart Disease?
Heart valve disease can develop for different reasons.
Possible causes include:
- Age-related changes to the heart valves
- Congenital heart valve abnormalities
- Previous rheumatic fever
- Infection affecting a heart valve, known as infective endocarditis
- Changes to the heart following a heart attack
- Cardiomyopathy or enlargement of the heart
- Calcium deposits affecting a valve
- Other cardiovascular conditions that alter the structure or function of the heart
In some people, a valve abnormality may be present for years before symptoms develop.
What Are the Symptoms of Heart Valve Disease?
Mild valvular heart disease may not cause noticeable symptoms. Some people first learn they have a valve abnormality when a heart murmur is detected during a routine examination or when an echocardiogram is performed for another reason.
When symptoms occur, they can include:
- Shortness of breath, particularly during physical activity
- Reduced ability to exercise
- Unusual fatigue
- Chest pain or discomfort
- Palpitations
- Dizziness or light-headedness
- Fainting
- Swelling of the feet, ankles or legs
Symptoms alone cannot determine whether someone has valvular heart disease or how severe it is. Similar symptoms can occur with other cardiac and non-cardiac conditions.
What Is a Heart Murmur, and Does It Mean I Have Valve Disease?
A heart murmur is an additional sound that may be heard when a doctor listens to the heart with a stethoscope.
Some murmurs are associated with abnormal blood flow across a heart valve, but having a heart murmur does not necessarily mean that significant heart disease is present.
If a murmur is detected, an echocardiogram may be recommended to examine the structure and function of the valves and determine whether further assessment is needed.
How Is Valvular Heart Disease Diagnosed?
Assessment usually begins with a discussion of symptoms, medical history and cardiovascular risk factors, followed by a physical examination.
Depending on the findings, investigations may include:
Echocardiography
An echocardiogram uses ultrasound to produce images of the heart. It can assess how the valves open and close, the direction and speed of blood flow, the size of the heart chambers and the heart’s pumping function.
It is one of the main investigations used to assess suspected or known valvular heart disease.
Electrocardiogram (ECG)
A 12-lead ECG records the heart’s electrical activity. It may help identify changes in heart rhythm or other findings associated with cardiac conditions.
Exercise or Stress Testing
In selected patients, exercise testing may be used to assess symptoms and how the cardiovascular system responds to physical activity.
Trans-Oesophageal Echocardiography
For some patients, a trans-oesophageal echocardiogram may be considered when more detailed images of the heart valves are required.
A specialised ultrasound probe is passed into the oesophagus, which lies close to the heart, allowing certain cardiac structures to be viewed in greater detail.
Other investigations may be recommended depending on the valve affected, the severity of the condition and whether an intervention is being considered.
Does Valvular Heart Disease Always Need Treatment?
Not necessarily.
Some people with mild or moderate valve disease may not require an immediate procedure. Instead, the condition may be monitored through clinical reviews and repeat echocardiograms.
Management may also include treatment of related cardiovascular conditions or symptoms where appropriate.
If valve disease becomes more severe, causes symptoms or begins to affect heart function, a cardiologist may discuss whether an intervention should be considered.
The timing of treatment is individual and depends on factors such as the valve involved, severity of the abnormality, symptoms, heart function and the patient’s overall health.
How Is Valvular Heart Disease Treated?
Treatment depends on the type and severity of the valve condition.
Medical Management
Medication does not repair a structurally abnormal heart valve, but it may be prescribed to manage certain symptoms or associated conditions.
Depending on the individual, this could include treatment for high blood pressure, fluid retention, abnormal heart rhythms or other cardiovascular conditions.
Heart Valve Repair
In selected cases, a heart valve may be surgically repaired rather than replaced. The suitability of valve repair depends on the valve involved and the nature of the abnormality.
Heart Valve Replacement
When a valve cannot be repaired or when replacement is considered more appropriate, it may be replaced with a mechanical or biological valve.
The choice of valve and procedure depends on individual clinical factors.
Transcatheter Valve Procedures
For selected patients, certain valve conditions may be treated using catheter-based procedures rather than open-heart surgery.
For example, transcatheter aortic valve implantation (TAVI/TAVR) may be considered for some patients with severe aortic stenosis.
Whether a surgical or transcatheter approach is appropriate requires assessment by the relevant cardiovascular specialists.
What Happens If Heart Valve Disease Is Left Untreated?
The course of valvular heart disease varies considerably.
Mild disease may remain stable for a prolonged period. More significant valve abnormalities can progressively place additional strain on the heart and may eventually affect the heart chambers, heart rhythm or pumping function.
This is why follow-up may be recommended even when a person has few or no symptoms.
The frequency of monitoring depends on the type and severity of the valve abnormality and the individual’s clinical circumstances.
When Should I See a Cardiologist About Possible Valve Disease?
A cardiac assessment may be appropriate if:
- A heart murmur has been detected
- An ECG, echocardiogram or other test has shown an abnormality
- You have unexplained shortness of breath
- Your exercise tolerance has noticeably decreased
- You experience recurrent palpitations, dizziness or fainting
- You have persistent swelling of the legs or ankles
- You have previously been diagnosed with heart valve disease and require follow-up
Sudden or severe chest pain, significant difficulty breathing or loss of consciousness should be assessed urgently rather than waiting for a routine cardiology appointment.
Valvular Heart Disease Assessment at Apex Heart Clinic
Apex Heart Clinic provides assessment and management of cardiovascular conditions, including valvular heart disease, at Gleneagles Hospital, Singapore.
Dr Daniel Yeo is a Senior Consultant Cardiologist and Medical Director of Apex Heart Clinic. His clinical practice includes echocardiography and the assessment and management of heart conditions.
Where a patient requires a cardiac procedure or surgery, care may involve coordination with the relevant cardiac subspecialists and cardiac surgeons based on the patient’s condition and treatment requirements.
Discuss Your Heart Valve Condition
If you have been diagnosed with a heart valve condition, have a heart murmur or are experiencing symptoms that may require cardiac assessment, a consultation can help determine whether further investigation or follow-up is appropriate.
Frequently Asked Questions
Is a leaking heart valve serious?
A leaking heart valve, or valve regurgitation, can range from mild to severe. Mild regurgitation may require monitoring rather than intervention, while more significant regurgitation may affect heart function or cause symptoms. An echocardiogram can help assess its severity.
Can you have heart valve disease without symptoms?
Yes. Some people with valvular heart disease have few or no noticeable symptoms, particularly during the earlier stages. The condition may instead be identified through a heart murmur or cardiac imaging.
Can an ECG detect heart valve disease?
An ECG can provide information about the heart’s electrical activity and rhythm, but it does not directly show how the heart valves are functioning. Echocardiography is commonly used to assess the structure and function of the heart valves.
How often should heart valve disease be checked?
Follow-up intervals vary according to the valve involved, the severity of the condition, symptoms and changes in heart function. Your cardiologist can advise how frequently clinical reviews or repeat echocardiograms are appropriate.
Does every damaged heart valve need surgery?
No. The need for an intervention depends on the type and severity of valve disease, symptoms, heart function and other clinical factors. Some valve conditions can be monitored without immediate surgery.
