The human heart has four valves: the aortic, mitral, pulmonary, and tricuspid valves. Heart valve disease occurs when one or more of these valves do not work properly. Normally, these valves have tissue flaps that open to let blood flow through or out of your heart, and then shut to keep the blood from flowing backward. All of this is highly coordinated with the heart beat. The main function of the valves is to keep blood flowing in one direction through the heart’s chambers. What can happen when heart valves are not working properly?
- Blood can leak back through the valve in the wrong direction; this “backflow” is called regurgitation.
- One of the valves (the mitral valve) can develop “floppy” flaps that don’t close tightly. The scientific name for this is mitral valve prolapse and it is one of the most common heart valve conditions.
- Stenosis (or a narrowing of a valve) occurs when the flaps of a valve thicken, stiffen, or fuse together. This prevents the valve from fully opening, making it harder for blood to be pumped through the valve.
- A number of valve structural problems can be present at birth (called congenital valve disease). Valves might not form properly; they may not have enough tissue flaps, they may be the wrong size or shape, or they make lack an opening through which blood can flow properly (called atresia).
Heart valve disease is common, affecting over 5 million individuals in the United States. For some people, the condition will stay largely the same over their lifetime and never need treatment or intervention. For other people, their heart valve problem will worsen over time, eventually requiring medication, medical procedures, or even surgery to repair or replace the defective valve. Left untreated, advanced valve disease can cause heart failure, stroke, blood clots, or sudden cardiac death.
Degenerative valve disease, the most common form of valvular heart disease in industrialized nations, is an emerging health problem with broad consequences. An estimated 95,000 valve surgery procedures are performed each year in the U.S. and aortic valve disease alone is responsible for more than 25,000 annual deaths. Increasing age is the greatest risk factor for valve disease and an estimated one in eight people age 75 years or older have at least moderate heart valve disease.
The following is a summary of some of the latest recommendations for management of patients with heart valve disease. These recommendations may not apply to all patients and it is always a good idea to discuss your particular situation with your personal physician.
LIFESTYLE MODIFICATIONS
Currently, no medicines can cure heart valve disease. However, lifestyle changes and appropriate medications can relieve symptoms and delay complications for many years. For example, in the case of aortic stenosis, it may take decades of progression to go from detection of the abnormality to a need for intervention. Therefore, aortic stenosis may be amenable to lifestyle changes that can further reduce the progression of this disease. Besides age, the other major risk factors for acquired heart valve disease are some of the same risk factors as for coronary artery disease, such as high blood pressure, high cholesterol levels, smoking, insulin resistance, diabetes, overweight/obesity, lack of physical activity, and a family history of valve disease
1. Aortic stenosis (narrowing of the aortic valve) is one of the most common valve diseases associated with aging, and is the most common indication for surgical valve replacement. Studies suggest that a link exists between smoking and degenerative aortic valve diseases, like aortic stenosis. Moreover, smoking also contributes to other heart diseases, including coronary artery disease. Quitting smoking is therefore essential to maintenance of heart valve health and overall heart health. There are several approaches that can help individuals who want to quit smoking. Approved medications include nicotine replacement therapies that are available in many forms, such as gum, lozenges, inhalers, nasal spray, and nicotine patches. Non-nicotine prescription drugs which reduce the severity of nicotine cravings and withdrawal symptoms are also available. The likelihood that you will successfully quit smoking is increased further with participation in stop smoking programs that are offered at many local hospitals and health centers. Patients with advanced heart valve disease should check with their physician before starting any new medications or nicotine replacement products.
2. To relieve the symptoms of heart conditions related to heart valve disease, your doctor will likely encourage you to live your life in a CardioSmart manner. All of the following are important—weight control; increased physical activity; moderation of alcohol consumption; limited sodium intake; and maintenance of a diet high in whole grains, fresh fruits, vegetables, and low-fat dairy products. You should reduce your intake of saturated fats (found mostly in animal products) to less than 7% of total calories, and greatly reduce intake of trans fats (also in animal products and most snack foods), and limit cholesterol intake. All patients are encouraged to increase their consumption of omega-3 fatty acids, found in fish and in supplement form.
3. In general, the recommendation to increase physical activity applies to patients with heart valve disease, especially when coronary artery disease is also present. However, some precautions are necessary. For example, physical activity is not usually restricted in patients with mild aortic stenosis; these patients can often even participate in competitive sports. On the other hand, patients with moderate-to-severe aortic stenosis should avoid sports that place a high demand on large muscle groups. Because one-size does not fit all when it comes to valve disease and physical activity, it is important to check with your physician for guidelines regarding an exercise program which is appropriate for you. It may be helpful for certain patients with valve disease to undergo a medically supervised exercise test before they begin an exercise program.
GOALS FOR RISK FACTOR MANAGEMENT
1. Since hypertension (high blood pressure) is a major contributor to certain types of heart valve disease, it is an important target for reducing risk. A number of important lifestyle modifications are recommended for anyone with a blood pressure of 120/80 mmHg or greater. These recommendations include: weight reduction if overweight or obese; a daily diet rich in fruits, vegetables, and low-fat dairy products, as well as an overall diet low in total fat and saturated fat; and a reduction of sodium (salt) to no more than 2.4 grams per day. Blood pressure should be controlled so that readings at rest consistently fall below 140/90 mm Hg. Patients who also have diabetes or kidney disease should maintain their resting blood pressure levels below 130/80 mm Hg. Most people with hypertension will require two or more drugs to reach their blood pressure goal.
2. Excess weight can increase the workload on the heart and magnify any effects related to underlying valve disease. Individuals should achieve and maintain a BMI (body mass index, a measure of weight related to height) between 18.5 and 24.9 kg/m2. Waist circumference should fall below 35 inches (89 cm) in women and 40 inches (102 cm) in men. When waist measurements are above these values, it is important to initiate lifestyle changes and consider treatment strategies for metabolic syndrome, if present.
3. Maintaining appropriate cholesterol levels and normal blood sugar readings is important in patients with heart disease and those at risk for developing heart disease.
DRUG THERAPIES
1. People with heart valve disease may be prescribed medicines (as required) to treat heart failure, lower blood pressure, and reduce cholesterol levels. Medication also may be prescribed to prevent irregular heartbeats, known as arrhythmias.
2. Medications to lower blood pressure were in the past universally recommended for patients with severe aortic regurgitation - even if those individuals had normal resting blood pressure readings. This unique group is no longer felt to clearly benefit from this approach.
3. Since several valve diseases or defects make people susceptible to blood clots, blood thinning drugs are sometimes recommended. These medications are required in people who have undergone surgery and now have one or more man-made or “mechanical” valves.
4. For many years, patients with various heart valve problems were instructed to take antibiotic prophylaxis prior to dental work and certain medical procedures in order to reduce the risk of endocarditis (an infection of the heart valves). These recommendations have recently changed, and far fewer patients now need to take these prophylactic antibiotics. The only patients who still require them are those with artificial heart valves, patients with complex congenital heart disease, and patients who have previously experienced endocarditis. If you have a heart valve abnormality but are not sure if you still need to take antibiotics prior to dental visits and other medical procedures, please check with your physician.
OTHER CONSIDERATIONS
Heart valve disease is usually a lifelong condition. Over time, the problem may worsen and require more than medications can offer. In these cases, valve repair or replacement may be indicated. Once you have undergone such a surgical procedure for valve disease, you may still need certain medications, and will require regular checkups for the rest of your life.
Technical considerations
1. Valve repair or replacement may be recommended for advanced valve disease or in people with less advanced disease but at high risk of lasting damage to their heart without surgical intervention. Whether heart valve repair or replacement is selected may depend on a number of factors, such as severity of the valve disease and your age and general health. You should talk to your cardiologist and your cardiac surgeon about the pros and cons of different approaches to your particular problem.
2. Many valves cannot be repaired. However, when feasible, heart valve repair is preferred over valve replacement. Based on superior outcomes, mitral valve repair is especially recommended over mitral valve replacement for the majority of patients with longstanding severe mitral regurgitation. Further, selective referral of patients with severe mitral regurgitation to surgical centers experienced in mitral valve repair is recommended.
3. Patients who require valve surgery but in whom repair is not feasible may be offered a metal (mechanical) valve or a tissue (bioprosthetic) valve (from a pig or human cadaver). Tissue valves offer the great advantage of not requiring the use of blood thinners after implantation, but are not as long lasting as mechanical valves. This means that if a tissue valve is implanted in a young individual, a repeat valve replacement surgery is highly likely during that patient’s lifetime. The decision to implant a tissue valve versus a mechanical valve therefore needs to include patient age and patient lifestyle issues (eg. desire to play competitive sports, in which case the tendency to bleed easily due to the presence of blood thinners would not be ideal). The guidelines recommend a patient age of 65 years as the threshold for implantation of a tissue as opposed to a mechanical valve in the aortic and mitral positions. The guidelines also make an allowance for patient preference to recommend a bioprosthesis in a patient under 65 years of age.
4. Certain heart valves that don’t open fully due to stenosis may be treated with a less invasive catheter procedure called balloon valvuloplasty. It’s similar to balloon angioplasty which is used to open a clogged artery. For some patients with mitral valve stenosis, balloon valvuloplasty may be preferred to surgical repair or replacement. It is not a cure, but using a balloon to increase blood flow through a narrowed heart valve can help relieve many of the symptoms of valve disease. In some infants and children, valve stenosis is caused by a congenital defect that can be repaired by a single balloon valvuloplasty. Not all narrowed valves are amenable to balloon valvuloplasty. Discuss this option with your cardiologist.
5. Although not widely available, there are some newer surgeries that utilize less invasive means to access the valves for surgical repair or replacement. These procedures use smaller incisions, cause less pain, and speed recovery time. Some cardiologists and cardiac surgeons are exploring these new procedures that are still largely experimental.
Unique situations impacting timing of surgery
1. In patients with chronic severe mitral regurgitation, valve surgery is recommended in patients with any symptoms, atrial fibrillation, or pulmonary hypertension (increased blood pressures in the lungs). Surgery is also recommended for patients without symptoms who display impaired left ventricular (LV) pumping function (ejection fraction 30-60%) or significant LV dilation (LV internal diameter at maximum contraction >40 mm).
2. A relatively common congenital valve abnormality is bicuspid aortic valve. Instead of the normal three leaflets, a bicuspid aortic valve has two. A bicuspid aortic valve can be associated with abnormalities of the aorta (the main blood vessel which carries blood away from the heart to the body). The ascending aorta (the very first part of the aorta attached to the heart) is especially likely to be affected by enlargement (dilatation). The guidelines recommend: a) serial imaging if the bicuspid aortic valve is associated with an ascending aorta diameter over 4.0 cm, b) surgery to repair the ascending aorta if the diameter is greater than 5.0 cm or if the diameter increases more than 0.5 cm/year, and c) repair of the ascending aorta at the time of aortic valve replacement if the diameter of the aorta is greater than 4.5 cm.
Valve disease and pregnancy
1. Usually, mild-to-moderate heart valve disease during pregnancy can be successfully managed through pregnancy, labor, and delivery with conservative measures such as medications and bed rest. Severe heart valve disease, however, can make pregnancy or labor and delivery much riskier than normal. Ideally, management of women with valve disease should begin before conception. A careful examination and assessment of heart function is needed to determine whether an individual woman will be able to tolerate the stresses on the heart during pregnancy, labor, and delivery. Women with severe valve disease should talk to their doctor about the option of valve repair or replacement before getting pregnant. These surgeries can be performed during pregnancy, but they increase the danger to both mother and fetus.
GUIDELINE-BASED STANDARDS OF CARE: WHAT YOU SHOULD KNOW
The American College of Cardiology (ACC) and the American Heart Association (AHA) work together on an ongoing basis to publish Guidelines addressing standards of care for the diagnosis, management and prevention of cardiovascular disease. The ACC/AHA Guidelines represent a consensus of expert medical opinion, with the goal of establishing a standard on which to base cardiovascular care decisions, serving the patient’s best interests.
The guidelines are intended to help health care providers and patients make informed, best-possible decisions regarding care for specific clinical circumstances. The ACC strongly believes that adoption of these standards leads to higher quality cardiovascular care, cost-effectiveness, and most importantly, better outcomes for patients.
Please note that the ACC/AHA Guidelines attempt to define practices that meet the needs of most patients in most circumstances. However, everyone is unique, and the extent to which the guidelines apply specifically to you should be a key point of discussion between you and your cardiologist or health care provider. The ultimate judgment regarding your care must be made by you and your healthcare provider together, in light of circumstances specific to you as a patient.
Although all ACC/AHA Guideline documents are freely available, and can be downloaded from the ACC’s Cardiosource web site, these documents are often extremely long, and written primarily for the healthcare provider. Here at CardioSmart you will find a summary of the key points from the Guidelines, written specifically with the patient in mind. We urge you to review these key points, print them out if you like, and engage your healthcare provider in a discussion of how the guidelines relate to you and your condition.
That is, after all, what being CardioSmart is all about – being empowered to work with your physician in managing your care to assure the best possible outcome!
If you’d like to read the full guidelines from which this summary is derived, please click on either of the links below. Please note that these documents are large, so please have patience while they load.
ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease
AHA/ACC Guidelines for Secondary Prevention for Patients With Coronary and Other Atherosclerotic Vascular Disease: 2008 Update