Heart Valve Disease

Overview

Heart valve disease occurs when one or more of the heart's four valves fails to work properly. The valves act as one-way gates that keep blood moving in the right direction through the heart's chambers and out to the body and lungs. When a valve does not open fully, blood flow is restricted. When a valve does not close properly, blood leaks backward. In either case, the heart must work harder to compensate.

When heart valve disease is mild, it may produce no symptoms for years. As the disease progresses and the heart's ability to compensate diminishes, symptoms gradually appear, and the condition can eventually lead to heart failure. With early diagnosis and appropriate monitoring, many patients live for years without symptoms. When the disease does advance, surgical or catheter-based procedures can repair or replace the affected valve.

Heart valve disease can occur at any age. Rheumatic fever, congenital valve abnormalities, age-related calcification, and infections are among the most common causes.

Types

Heart valve disease is classified both by which valve is affected and by the nature of the dysfunction.

Types of Valve Dysfunction

• Stenosis (narrowing). The valve leaflets thicken, stiffen, or fuse together. The valve cannot open fully and blood flow is restricted. The heart must work harder to force blood through the narrowed opening.
• Regurgitation (leaking). The valve does not close completely and blood leaks backward. The heart is overloaded because it must pump both the forward volume and the volume that has leaked back.
• Prolapse. The valve leaflets bulge backward into the upstream chamber during contraction. This is most commonly seen in the mitral valve. In mild cases, monitoring alone is sufficient. In some patients, prolapse leads to significant regurgitation.

Which Valves Can Be Affected

• Aortic valve disease. The valve between the left ventricle and the aorta. Aortic stenosis is one of the most common serious valve conditions and develops most often from calcification in older adults. In aortic regurgitation, blood leaks back from the aorta into the left ventricle.
• Mitral valve disease. The valve between the left atrium and the left ventricle. Mitral stenosis is most often a late complication of rheumatic fever. In mitral regurgitation, blood leaks back into the left atrium with each contraction of the left ventricle. Mitral valve prolapse is a very common and usually benign condition.
• Tricuspid valve disease. The valve between the right atrium and the right ventricle. Tricuspid regurgitation most often develops secondarily as a consequence of right ventricular enlargement caused by left-sided valve disease or pulmonary hypertension.
• Pulmonary valve disease. The valve between the right ventricle and the pulmonary artery. Most commonly seen in congenital heart disease.

Symptoms

Heart valve disease may produce no symptoms in its early stages. As the disease progresses and the heart can no longer fully compensate, symptoms develop. Their nature and severity depend on which valve is affected and how serious the dysfunction is.

• Shortness of breath. This is one of the most common symptoms. It may initially occur only during exertion, such as climbing stairs or walking briskly. Over time, breathlessness can develop at rest or when lying flat.
• Fatigue and weakness. When the heart cannot pump enough blood, the body receives less than it needs and a persistent sense of exhaustion may develop.
• Swelling in the legs and ankles. Fluid accumulation in the body can occur, particularly with right-sided valve disease or in advanced left-sided conditions.
• Palpitations or irregular heartbeat. Heart valve disease predisposes to atrial fibrillation and other rhythm disturbances, which can produce a sensation of a racing, fluttering, or irregular heartbeat.
• Chest pain or pressure. This occurs particularly in aortic stenosis and is often brought on by exertion.
• Dizziness or fainting. Especially in severe aortic stenosis, dizziness or fainting during or after exercise can occur. This symptom is particularly important and should always be taken seriously.
• Heart murmur. An abnormal heart sound heard through a stethoscope during examination may suggest a valve abnormality. Not all murmurs indicate disease — some are entirely harmless — but a murmur should always be evaluated by a doctor.

When to Seek Medical Care

See a doctor if you notice any of the following.

• Shortness of breath during activity or at rest
• Swelling in the legs or ankles
• Palpitations or a sensation of irregular heartbeat
• Unexplained fatigue and a decline in exercise capacity
• A heart murmur has been detected and you have not yet seen a cardiologist

Call emergency services immediately if you experience any of the following.

• Sudden, severe chest pain
• Fainting during or after exercise
• Sudden, severe shortness of breath
• A very rapid or markedly irregular heartbeat

Causes

Heart valve disease has several possible causes. The specific cause often depends on which valve is affected and the type of dysfunction present.

• Age-related calcification. One of the most common causes. As people age, calcium deposits can build up on the valve leaflets, causing them to stiffen and thicken. This process is particularly prominent in the aortic valve and is the most frequent cause of aortic stenosis in older adults. High blood pressure, high cholesterol, and diabetes can accelerate this process.
• Rheumatic fever. Untreated streptococcal throat infections can lead to rheumatic fever, which causes permanent damage to the mitral and aortic valves. This remains an important cause worldwide.
• Congenital valve abnormalities. Some people are born with structural valve defects. A bicuspid aortic valve — in which the aortic valve has two leaflets instead of the normal three — is the most common congenital valve abnormality. It can lead to earlier and more significant valve disease in adulthood.
• Infective endocarditis. Bacteria entering the bloodstream can settle on the valve leaflets and cause a destructive infection. Without prompt treatment, this can lead to rapid and severe valve damage.
• Heart attack. Damage to the heart muscle during a heart attack can injure the structures supporting the mitral valve, causing acute mitral regurgitation.
• Heart muscle disease and heart failure. Enlargement of the heart can cause the valve rings to dilate, leading to functional regurgitation. This is particularly common in the mitral and tricuspid valves.
• Radiation therapy. Radiotherapy to the chest can contribute to valve damage years after treatment.
• Certain medications. Some drugs have been associated with valve damage, typically after long-term use.

Risk Factors

• Older age. Valve calcification and degeneration increase significantly with age. Severe aortic stenosis is considerably more common in people over 75.
• Congenital valve abnormality. A bicuspid aortic valve or other structural defect present from birth predisposes to earlier and more severe valve disease.
• A history of rheumatic fever. A long-term consequence of untreated streptococcal throat infections that can lead to valve scarring and stenosis.
• High blood pressure and high cholesterol. These accelerate the valve calcification process.
• A prior episode of infective endocarditis. Previously infected valve tissue carries an ongoing risk.

Diagnosis

The diagnosis of heart valve disease is established through clinical assessment and imaging. Determining the specific type, which valve is affected, and the severity of dysfunction directly shapes the monitoring plan and the timing of any intervention.

• Medical history and physical examination. The doctor asks about when symptoms began, how they have progressed, and in what situations they are most noticeable. Auscultation of the heart with a stethoscope is a central part of the examination. A heart murmur — an abnormal sound produced by turbulent blood flow through a dysfunctional valve — is often the first clue to valve disease. The timing, character, and intensity of the murmur provide important information about the type and severity of the problem. Neck veins, lung sounds, and leg swelling are also assessed.
• Echocardiogram (heart ultrasound). This is the gold standard for diagnosing and assessing heart valve disease. It provides real-time images of the valve leaflets, their movement, and their function. It precisely measures the degree of stenosis or regurgitation and assesses the size of the heart chambers, wall thickness, and ejection fraction. When two-dimensional imaging is insufficient, three-dimensional echocardiography or transesophageal echocardiography — where an ultrasound probe is passed into the esophagus — provides much greater anatomical detail. Transesophageal echocardiography is particularly important before surgical or catheter-based interventions.
• Electrocardiogram (ECG). Records the heart's electrical activity. It can detect rhythm disturbances, electrical changes associated with chamber enlargement, and conduction abnormalities. Because atrial fibrillation is a common complication of valve disease, the ECG is important in this context as well.
• Chest X-ray. Can show cardiac enlargement and fluid accumulation in the lungs, providing supplementary information about the effect of valve disease on the heart.
• Cardiac MRI. Provides highly accurate measurements of chamber dimensions and function. It is used when echocardiographic imaging is suboptimal or when additional anatomical detail is needed. It can also quantify the volume of regurgitation with precision.
• Exercise stress test. May be used in patients who appear to have no symptoms but in whom the true exercise capacity is uncertain. Blood pressure, heart rate, and ECG responses during exercise provide information that can help determine the timing of intervention, particularly in aortic stenosis and mitral valve disease.
• Coronary angiography or coronary CT angiography. Evaluation of the coronary arteries is required before valve surgery or a catheter-based procedure. If significant coronary artery disease is present, it can be addressed at the same time as the valve intervention. Coronary assessment is especially important in people over 50 and in those with cardiovascular risk factors.

Treatment

Treatment of heart valve disease depends on the type and severity of the condition, which valve is affected, and the patient's overall health. Mild disease is managed with medications and regular monitoring. Advanced disease typically requires valve repair or replacement.

Medications

Medications do not correct the valve problem itself but relieve symptoms, protect the heart, and help prevent complications.

• Heart failure medications. Drugs that reduce the workload on the heart and prevent fluid accumulation help relieve breathlessness and swelling. ACE inhibitors or ARBs, beta-blockers, and diuretics are commonly used.
• Blood thinners. When atrial fibrillation is present, or when a mechanical valve has been implanted, anticoagulation is required to reduce the risk of clot formation and stroke. Most patients with a mechanical valve require lifelong warfarin therapy.
• Blood pressure medications. In aortic regurgitation in particular, medications that reduce vascular resistance can decrease the backward leak and slow adverse remodeling of the heart.
• Managing rhythm disturbances. Atrial fibrillation and other rhythm problems are managed with appropriate medications.
• Infective endocarditis prophylaxis. Some patients with certain valve conditions are advised to take antibiotics before dental procedures or specific surgeries to reduce the risk of valve infection. Discuss this with your cardiologist and inform your dentist about your valve condition.

Interventional and Surgical Treatments

When valve disease advances and adequate symptom control cannot be achieved with medications, repair or replacement becomes necessary. Both surgical and catheter-based options now exist.

• Valve repair. Whenever feasible, repairing the existing valve is preferred over replacing it. This approach is particularly successful for mitral valve disease. The repair preserves the natural valve tissue and restores its function through various surgical techniques. A repaired valve avoids the need for lifelong anticoagulation that a mechanical replacement would require and generally provides excellent durability.
• Biological valve replacement. Valves derived from animal tissue or human donor tissue provide natural flow characteristics and do not require long-term anticoagulation. However, they gradually deteriorate over time and may need to be replaced after ten to twenty years. They are generally preferred in older patients or in those who cannot safely take long-term anticoagulation.
• Mechanical valve replacement. Made from metal alloys, these valves are extremely durable and rarely require replacement. However, they carry a risk of clot formation, making lifelong warfarin anticoagulation mandatory. They are generally preferred in younger patients who can reliably manage long-term anticoagulation.
• TAVI (transcatheter aortic valve implantation). A catheter-based approach to treating aortic stenosis. A new valve is delivered through a catheter, most commonly passed through an artery in the groin, and deployed inside the diseased valve without open heart surgery. Originally reserved for patients at high surgical risk, TAVI is now also used in intermediate and lower surgical risk patients. Its key advantages include a faster recovery and shorter hospital stay.
• MitraClip and other catheter-based mitral interventions. In patients with significant mitral regurgitation who carry high surgical risk, catheter-based devices can reduce the leak without open surgery. The MitraClip clips the mitral valve leaflets together to reduce the backward flow of blood.
• Balloon valvuloplasty. A balloon catheter is used to widen a narrowed valve. This is most commonly applied to mitral stenosis and to pulmonary stenosis in appropriate patients. In aortic stenosis, it may be used as a temporary bridge but is not a long-term solution.

Complications

Untreated or inadequately managed heart valve disease can lead to serious complications over time.

• Heart failure. The most common and most significant long-term complication. The sustained increased workload on the heart gradually exceeds its compensatory capacity and heart failure develops.
• Atrial fibrillation. Particularly common in mitral valve disease. Atrial fibrillation both worsens symptoms and substantially raises the risk of stroke.
• Stroke. Clot formation associated with atrial fibrillation increases stroke risk. Patients with mechanical valves also carry a clot risk. Anticoagulation therapy reduces this risk.
• Infective endocarditis. Damaged valve surfaces provide a site where bacteria can settle and cause infection. Infective endocarditis can rapidly worsen valve damage and cause serious systemic illness.
• Sudden cardiac arrest. In severe and untreated valve disease, particularly advanced aortic stenosis, the risk of sudden cardiac arrest is elevated.

Lifestyle

Living with heart valve disease requires a long-term perspective. Depending on the type and severity of the condition, several aspects of daily life benefit from careful attention.

Physical Activity

Exercise recommendations in heart valve disease are individualized. Many people with mild valve disease and no symptoms can continue normal physical activity without restriction. In severe conditions such as critical aortic stenosis, vigorous exercise can trigger symptoms or carry risk. The type and intensity of activity that is safe for you specifically should be determined by your cardiologist.

Medications

Taking medications for valve disease consistently is essential. For patients with a mechanical valve, warfarin therapy requires particularly careful management. The dose is adjusted based on regular INR monitoring. Avoiding missed doses and being aware of foods and medications that can affect warfarin's activity is important. Do not stop any medication without consulting your doctor.

Protecting Against Infective Endocarditis

Some patients with valve disease are recommended to take antibiotics before dental procedures and certain surgeries to prevent valve infection. Inform your dentist and every treating doctor about your valve condition. Good oral hygiene is also an important measure for reducing the risk of endocarditis.

Salt and Fluid Intake

In patients with heart failure symptoms, reducing salt intake helps prevent fluid accumulation and relieves breathlessness and swelling. Ask your doctor for a specific daily salt target. In some patients, total fluid intake may also need to be monitored.

Daily Weight Monitoring

Weighing yourself at the same time each morning and recording the result is a practical way to detect fluid buildup early. A significant weight gain over a short period should prompt you to contact your doctor.

Regular Follow-up

Heart valve disease requires regular cardiology monitoring. Echocardiography is used at defined intervals to assess valve function and the size of the heart chambers. The frequency of follow-up depends on the severity of the disease. Long-term monitoring is also necessary after surgical or catheter-based intervention. Contact your doctor or seek emergency care if any of the following develop.

• Shortness of breath that returns or worsens
• Swelling in the legs or ankles that is new or increasing
• Chest pain or pressure
• Fainting or nearly fainting
• Palpitations or a sensation of irregular heartbeat
• Unexplained fever with sweating and fatigue, which may suggest an infection of the valve

Preparing for Your Appointment

Coming prepared to an appointment for heart valve disease helps your doctor make a more accurate assessment and choose the most appropriate treatment for you.

What You Can Do

• Write down when symptoms began and how they have progressed.
• Mention if a heart murmur has previously been detected and when.
• Share any history of rheumatic fever or streptococcal throat infections in childhood.
• List all medications, supplements, and herbal products you are currently taking.
• Bring any previous echocardiography reports if you have them.
• Mention if you have any upcoming dental procedures or surgical plans.
• Write your questions down before the appointment.

Questions You May Wish to Ask Your Doctor

• Which valve is affected and how serious is the disease?
• Do I need a surgical or catheter-based intervention now or in the future?
• If intervention is needed, would repair or replacement be more appropriate?
• Would a biological or a mechanical valve replacement be better suited to my situation?
• Is TAVI or a catheter-based option available for me?
• Do I need to take antibiotics before dental treatments?
• What type and amount of exercise is appropriate for me?
• How often do I need follow-up appointments?

Questions Your Doctor May Ask You

• When did symptoms begin and how have they progressed?
• Has a heart murmur been detected previously?
• Did you have rheumatic fever in childhood?
• Do you have any other known heart conditions?
• What medications are you currently taking?
• Do symptoms worsen during exercise?
• Have you had any prior heart surgery?