An Overview of Heart Valve Disease

The purpose of the four heart valves (the tricuspid, pulmonary, mitral, and aortic valves) is to make sure that when the heart beats, the blood flows freely in the proper direction. If one or more of the heart’s valves becomes diseased, either the free flow of blood through the heart becomes obstructed (stenosis), or blood may leak backward across the damaged valve (regurgitation)—or both. Either kind of problem, if not monitored regularly and treated effectively, can lead to heart failure, as well as other cardiac problems.

The consequences of heart valve disease depend on which valves are involved, whether the chief problem is stenosis or regurgitation, and the extent of the valvular damage. If you have valvular heart disease, you need to work closely with your cardiologist to make sure the condition of your valvular disorder, and its need for treatment, are reassessed regularly.

The Four Heart Valves and What They Do

View the four heart valves.

The heart has four chambers—a right and left atria, and a right and left ventricle. Each valve is situated in the opening between two chambers and attached to the opening by a fibrous ring, called an annulus. Attached to the annulus are two or three leaflets (sometimes called cusps) that function as “flaps.” The mitral valve has two leaflets; all the other valves have three leaflets.

As the heart beats, the leaflets open and close. When the leaflets are open, blood can flow across the valve. When the leaflets are closed, blood flow across the valve stops.

The right ventricle is guarded by the tricuspid and pulmonary valves. The tricuspid valve lies between the right atrium and the right ventricle. When the right atrium contracts, the tricuspid valve opens and allows blood to enter the right ventricle. Then, when the right ventricle contracts, the tricuspid valve closes (to prevent blood from leaking back into the right atrium), and the pulmonary valve opens to allow the blood being pumped by the right ventricle to flow into the pulmonary artery and out to the lungs.

The left ventricle is guarded by the mitral valve and the aortic valves. The mitral valve, which lies between the left atrium and left ventricle, opens when the left atrium contracts to let the blood flow into the left ventricle. When the left ventricle beats, the mitral valve closes and the aortic valve opens to direct the pumped blood into the aorta and out to the body’s tissues.

What Kinds of Problems Can Affect the Heart Valves?

To repeat, the heart valves accomplish two fundamental things: They assure that when the heart beats, blood flows through the heart freely and moves only in the right direction. So it makes sense that if the heart valves become diseased, two general kinds of problems result.

First, heart valve problems can cause the valve to become partially obstructed, so that blood no longer flows freely across it. This condition is called valvular stenosis. When a heart valve becomes stenotic, the cardiac chamber that must push blood across the narrowed valve has to work substantially harder to push the blood out. This causes the pressure in that chamber to increase, which eventually causes the heart muscle to thicken (to become “hypertrophic”), and eventually can cause that muscle to fail.

Second, heart valve disease can cause the valve to become incompetent; that is, the valve fails to close completely and blood is able to flow backward across the valve when it is supposed to be closed. This condition is called valvular regurgitation. Regurgitation causes the affected ventricle to pump a greater volume of blood than normal, which can lead to dilation of the cardiac chambers, weakening of the heart muscle, and eventually, heart failure.

So, both valvular stenosis and valvular regurgitation can lead to heart failure. In addition, cardiac valve disease is strongly associated with an increased risk of cardiac arrhythmias, especially atrial fibrillation.

Any of the four cardiac valves can become either stenotic or regurgitant, and some diseased heart valves can display both of these problems at the same time. The severity of heart valve disease depends on the amount of stenosis or regurgitation that is being produced. With most kinds of valvular heart disease, the severity of the condition—and its effect on the heart’s function—can progress significantly as time goes by. Even “mild” heart valve disease must be taken seriously and be followed periodically by a competent doctor.

What Conditions Cause Heart Valve Disease?

Valvular heart disease can result from a number of different medical conditions. The most common causes of heart valve disease include:

  • Valvular Calcification: Calcium deposits can form on the heart valves, for no apparent reason, in association with aging. Valvular calcification tends to be especially likely with the mitral valve and, to a lesser extent, with the aortic valve. In many cases, valvular calcification never causes any significant change in the function of the valve. But it can produce either stenosis or regurgitation, so anyone who has valvular calcification needs to be followed regularly to reassess the condition.
  • Cardiac Dilation: If a cardiac chamber becomes dilated, it can eventually cause the annulus of the associated cardiac valves to also become dilated, which, in turn, can prevent the valve leaflets from closing completely. Valvular regurgitation can result. Cardiac dilation can occur with many kinds of heart disease. Commonly, the dilation that can occur after a heart attack, or with dilated cardiomyopathy, is accompanied by dilation of the mitral valve or tricuspid valve, leading to mitral or tricuspid regurgitation.
  • Congenital Heart Disease: Many types of congenital heart disease are associated with valvular deformities that can produce stenosis or regurgitation. The most common types of valve problems seen with congenital heart conditions are pulmonary stenosis, bicuspid aortic valve disease (in which the aortic valve has only two cusps instead of three, which can lead to aortic stenosis), and mitral valve prolapse.
  • Infectious Endocarditis: Infectious endocarditis, an infection of the lining of the heart and especially of the heart valves, can lead to heart valve damage, usually regurgitation. The valvular disorders caused by infectious endocarditis can progress slowly, but this is one condition that may often produce acute, and perhaps catastrophic, heart valve regurgitation.
  • Rheumatic Heart Disease: Rheumatic heart disease is a form of heart valve damage that is sometimes seen after a person has had rheumatic fever. While rheumatic heart disease is far less common in Western countries that it was 50 years ago, it is still a major concern in many parts of the world. Preventing rheumatic fever by aggressively treating strep throat remains very important.
  • Other Medical Conditions: Heart valve disease can result from several other medical conditions, including syphilis, connective tissue diseases (such as lupus), various tumors, aortic aneurysm, carcinoid, and radiation therapy to the chest.

Symptoms of Heart Valve Disease

In most cases, heart valve disease produces no symptoms at all until the heart muscle becomes damaged enough to begin to fail. When symptoms do occur, they tend to be the same as the symptoms of heart failure. These include dyspnea (shortness of breath); generalized weakness; lightheadedness; or edema (swelling) in the ankles, feet or the abdomen.

Arrhythmias may also result from heart valve disease; as noted, the risk of atrial fibrillation is especially increased. Symptoms of cardiac arrhythmias may include episodes of palpitations, lightheadedness, weakness, or poor exercise tolerance.

In most people, symptoms of valvular heart disease are usually a late manifestation of the disorder. Ideally, a person who has heart valve disease will have been diagnosed well before symptoms develop, so that treatment can be instituted before irreversible heart muscle damage has occurred.

Sometimes, however, heart valve disease can be an acute problem and not a chronically progressive one. Acute valvular heart disease can occur, for instance, as a result of heart muscle damage from a heart attack, or from acute damage to the heart valves from infectious endocarditis or rheumatic heart disease.

But much more often, heart valve disease is a chronic, progressive disorder that can be diagnosed well before symptoms develop. Early diagnosis, of course, is the key.

Diagnosing Valvular Heart Disease

The early diagnosis of heart valve disease is very important to its optimal management. Ideally, treatment is instituted before the heart muscle begins to fail and irreversible heart damage is done. But in order to do so, it is often important to know that the valve disease is present well before any symptoms ever develop.

Early heart valve disease is one of those asymptomatic medical problems that usually can be detected early on by a routine medical evaluation—and it’s one of the reasons we’re all encouraged to have those routine checks.

The first indication of a heart valve problem is usually the detection of a heart murmur during a physical examination. Either valvular stenosis or valvular regurgitation produces a certain amount of turbulence of the blood flow within the heart. This turbulence creates a sound that a doctor can hear with a stethoscope (a heart murmur). Not all heart murmurs indicate a heart problem, though; many are so-called “innocent” murmurs, that is, they are caused by a bit of turbulence that can be present in almost any normal heart.

If your doctor detects sounds that may indicate valvular heart disease, an echocardiogram is very good at distinguishing between a heart valve problem and an innocent murmur. With an echocardiogram, a definitive diagnosis can be made of virtually any type of heart valve problem.

If valvular disease is present, the echocardiogram also can objectively measure the extent of the problem. Several specific measurements can be made of blood flow patterns and cardiac chamber size, and these measurements can be compared to those from subsequent echo tests in order to determine how quickly the valve problem is worsening (if at all).

Specific Heart Valve Problems and Their Treatment

Mitral Stenosis: In mitral stenosis, obstruction of the mitral valve reduces the flow of blood from the left atrium to the left ventricle. Over time, pressure builds up in the left atrium, eventually causing pulmonary artery hypertension and heart failure involving mainly the right side of the heart. Treatment is surgical repair or replacement of the mitral valve, and the timing of surgery is critical. Once the need for surgery is established, the optimal type of mitral stenosis surgery needs to be determined for each individual.

Mitral Regurgitation: Mitral regurgitation, which produces the back flow of blood from the left ventricle to the left atrium, is the most common type of heart valve disease because it has so many causes. For instance, the chief significance of mitral valve prolapse (MVP) is that it can sometimes produce significant mitral regurgitation. Mitral regurgitation can cause dangerous enlargement in both the left atrium and left ventricle, and unless it is treated can lead to irreversible heart failure. The optimal timing of surgical treatment depends on the stage of the regurgitation. Several surgical approaches are available for treating mitral regurgitation.

Aortic Stenosis: In aortic stenosis, the aortic valve becomes partially obstructed, making it more difficult for the left ventricle to eject blood out to the body’s tissues. It leads to hypertrophy of the muscle of the left ventricle, and eventually to heart failure. In addition, if the amount of blood the heart can pump is decreased substantially because of the obstruction, syncope or even sudden death can occur. In fact, syncope due to aortic stenosis ought to be treated as a medical emergency, since it indicates that the aortic valve is critically narrowed. As with any kind of valvular heart disease, mild aortic stenosis needs to be observed closely over time. If the condition becomes significant enough, aortic valve surgery will be required.

Aortic Regurgitation: With aortic regurgitation, the aortic valve becomes leaky so that blood washes backward from the aorta into the left ventricle. This back flow of blood greatly increases the work of the left ventricle. If the regurgitation is significant, the ventricle eventually becomes greatly dilated and heart failure ensues. Treatment of significant aortic regurgitation requires surgical replacement of the aortic valve.

Tricuspid Stenosis: Tricuspid stenosis, partial obstruction of the tricuspid valve, is the least common of the major valvular diseases. It is most often seen in people who have had rheumatic heart disease and, in most cases, is accompanied by disease in other cardiac valves. If significant, tricuspid stenosis causes easy fatiguability and reduced exercise tolerance. However, symptoms caused by disease in one of the other valves usually occurs well before the tricuspid stenosis begins to produce symptoms. Consequently, surgical treatment of tricuspid stenosis (which consists of valvular repair rather than replacement) almost always happens as an “add-on” procedure, when surgery is necessary to treat a more severely affected heart valve.

Tricuspid Regurgitation: In tricuspid regurgitation, blood leaks across the tricuspid valve from the right ventricle back into to the right atrium. Tricuspid regurgitation is most often caused by dilation of the tricuspid annulus that occurs as the result of pulmonary artery hypertension, heart failure, or pulmonary embolus. The tricuspid regurgitation itself is often relatively mild and often does not require surgical treatment. A careful evaluation to look for an underlying medical problem is important, since treating the underlying problem often results in substantial improvement in tricuspid regurgitation.

Pulmonary Stenosis: Pulmonary stenosis, obstruction of the pulmonary valve, is usually a congenital disorder that is most often associated with tetralogy of Fallot, Noonan syndrome (a genetic disorder with cardiac abnormalities, short stature, chest deformities, and learning problems), or congenital rubella. Pulmonary stenosis is usually diagnosed at birth or shortly thereafter. If severe, it can produce failure of the right side of the heart. Mild pulmonary stenosis can be a completely benign condition that requires no therapy. If the condition is more serious, it can often be treated with balloon valvuloplasty, a minimally invasive catheterization procedure.

Pulmonary Regurgitation: In pulmonary regurgitation, blood leaks across a closed pulmonary valve from the pulmonary artery into the right ventricle. The most common cause of pulmonary regurgitation is pulmonary artery hypertension, which can produce dilation of the pulmonary valvular annulus to the point that the pulmonary valve can no longer close completely. If severe, pulmonary regurgitation can cause the right heart to become dilated, and heart failure can ensue. Generally, the treatment of pulmonary regurgitation is to take steps to reduce the pulmonary artery pressure. Surgery is not often needed.

Is There Non-Surgical Treatment For Valve Disease?

Heart valve disease is fundamentally a mechanical problem. To address the root cause, surgery is usually the only option.

However, in many cases medical therapy may be available that can help. Sometimes, medications can help stabilize the heart and slow the progression of valve disease. This is especially the case with many kinds of valvular regurgitation, in which the valve problem is caused by the dilation of a cardiac chamber. Aggressive medical treatment directed at treating underlying hypertension or dilated cardiomyopathy, or to prevent ventricular remodeling after a heart attack, or even to control the heart rate in atrial fibrillation, for instance, may greatly reduce the chances of developing significant mitral or tricuspid regurgitation.

For this reason, it is usually a good idea for people with valvular heart disease to be seen regularly by a cardiology specialist, who can readily address any associated cardiovascular problems.

Living With Heart Valve Disease

If you have heart valve disease, there are some things you need to do to optimize your chances of living a long and healthy life. You should learn everything you can about the type of valvular disorder you have, and the extent of your valve problem. If you are on medications to help your heart work more efficiently, you need to take them regularly and report any trouble with them to your doctor.

For that matter, you need to keep your regular appointments with your doctor. While this is important for anyone, it is especially important for a person who has a heart valve problem, since valvular heart disease often progresses over time. You should talk to your doctor about whether you need to take antibiotic prophylaxis for endocarditis.

Finally, since you already have a cardiac problem, you should do everything you can to reduce your odds of developing other kinds of cardiovascular disease: Don’t smoke; maintain a healthy diet and healthy weight; get plenty of exercise; and, if you have hypertension or diabetes, make sure you have these conditions under optimal control.

A Word From Verywell

Valvular heart disease can be a very serious problem. But with early detection, regular medical follow-up, and the availability of modern medical and surgical care, today most people with heart valve disease can expect to live long and healthy lives.

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Article Sources
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  • Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63:e57.