Heart Valve Disease

What are heart valves?

There are four valves in the heart, the aortic and mitral valves are situated on the left side of the heart. The tricuspid and pulmonary valves are situated on the right side of the heart. Heart valves allow blood to be directed around the heart and when working normally allow the blood to flow in one direction. They open and close with every heartbeat - that's 100,000 times every day!

What is heart valve disease?

Heart Valve Disease is a term used to describe heart valves which are not functioning normally. Sometimes people are born with abnormal heart valves (congenital abnormalities) or the valve disease can be acquired due to degeneration (wear and tear), infection or previous rheumatic fever.

When valves do not function correctly they either become stenosed (narrowed) or regurgitant (leaky).

Heart valve disease is usually diagnosed when the doctor listens to your heart and hears a murmur. The term murmur is used to describe a sound caused by abnormal blood flow across a diseased heart valve. 

Most of the time, heart valve disease does not cause any symptoms but simply needs monitoring. If treatment of valve disease is necessary, options for treatment include open heart surgery (heart valve replacement or repair) or keyhole operations. 

Do I need to change my lifestyle if I have heart valve disease?

As with any type of heart valve disease, it is important that you follow a healthy diet and keep your weight within a normal range. If you smoke it is advisable that you stop. Your GP can guide you to support to help you stop smoking. Most patients with heart valve disease will be encouraged to take regular exercise but you should discuss this with your Healthcare Professional. If you are planing pregnancy you should discuss this with your Healthcare Professional first and let them know immediately if you become pregnant. Patients with heart valve disease should maintain good oral hygiene and visit the dentist regularly.

Aortic stenosis

What is the aortic valve?

The aortic valve is the main outlet valve of the heart which allows blood to exit the heart with every heartbeat. Normal aortic valves have three leaflets, but around 1 in 50 people are born with an abnormal heart valve which has two leaflets, known as a bicuspid aortic valve.

What is aortic stenosis?

Aortic stenosis is a condition where the aortic valve becomes thickened or calcified (bony) and is less able to open. As a result, the blood flow across the valve is abnormal and this means a heart murmur can be heart when the heart is listened to with a stethoscope. 

What causes aortic stenosis?

The most common cause of aortic stenosis is age-related degeneration (wear and tear) and as a result most people who have the condition are over the age of 60. In people born with an abnormal 'bicuspid' valve, the valve can become stenosed (thickened / narrowed) at a younger age, and people with a bicuspid valve can be affected at any stage in their lives. Sometimes in addition to being narrowed, the aortic valve can also be leaky (aortic regurgitation). Patients with both aortic valve narrowing (stenosis) and leaking (regurgitation) have a condition called mixed aortic valve disease. 

What are my treatment options if I have aortic stenosis?

Aortic stenosis is a chronic (long term) condition. It can be graded into three categories; mild, moderate and severe.

Regardless of the severity of aortic stenosis, if you have no symptoms then it is likely that the Heart Valve Team will keep you under regular clinic review with regular echocardiograms (cardiac ultrasound). Patients with aortic stenosis are often followed up for many years without symptoms.

If you have severe aortic stenosis AND you have symptoms then you may be referred for aortic valve intervention. Aortic valve intervention can either be performed as an operation (open heart surgery or minimal access surgery with aortic valve replacement) or as a keyhole intervention (Transcatheter aortic valve implantation, often known as TAVI). 

Due to the importance of symptoms in patients with aortic stenosis, it is important to contact your Healthcare Professional if you develop symptoms in between clinic appointments. 

Is aortic stenosis associated with any other conditions?

In patients with bicuspid aortic valve, there can also be abnormalities of the main blood vessel leaving the heart (aorta). If you are at risk of aortic abnormalities then you may undergo regular ct or MRI scans of the aorta in addition to regular echocardiograms (cardiac ultrasound tests). 

Aortic regurgitation

What is the aortic valve?

The aortic valve is the main outlet valve of the heart which allows blood to exit the heart with every heartbeat. It is a one way valve that closes after the blood has left the heart. It is attached to the main blood vessel exiting the heart known as the aorta. 

What is aortic regurgitation?

Aortic regurgitation is a condition where the one-way aortic valve doesn't close tightly and therefore becomes leaky. Blood exits the heart when the left ventricle (heart muscle) pumps. As the valve is leaky and doesn't close properly, when the left ventricle (heart muscle) relaxes blood is able to leak backwards from the aorta (main exit blood vessel) back into the left ventricle of the heart. 

When the heart is listened to with a stethoscope, the abnormal blood flow results in a sound known as a heart murmur. Aortic regurgitation is usually diagnosed following an echocardiogram (also known as an echo or cardiac ultrasound).

What causes aortic regurgitation?

There are many reasons the aortic valve can be leaky. It can be due to a problem with the valve (valve-related causes). It can also be due to a problem with the aorta (main blood vessel leaving the heart). If the aorta is stretched/enlarged then the valve is unable to close properly resulting in a valve leak (aorta-related causes). 

Valve-related causes of aortic regurgitation

Bicuspid aortic valve (people born with two valve leaflets instead of three)

Previous endocarditis (valve infection)

Valve degeneration (wear and tear)

Rheumatic fever

Aorta-related causes of aortic regurgitation

Longstanding high blood pressure

Diseases affecting elastic tissues of the arteries known as connective tissue disease (eg Marfans, Ehlers-Danlos)

Idiopathic aortic dilatation, which is an unexplained stretch of the aorta

What treatment options are available?

Aortic regurgitation is a chronic (long term) condition. It can be graded into three categories; mild, moderate and severe.

Regardless of the severity of aortic regurgitation, if you have no symptoms then it is likely that your Healthcare Professional will keep you under review with a clinic visit and echocardiogram (echo or cardiac ultrasound) on a regular basis. Patients with aortic regurgitation are often followed up for many years without symptoms. Most patients with mild aortic regurgitation will not need follow up. 

If the valve has severe aortic regurgitation (is severely leaky) and you have symptoms then you may be referred for aortic valve replacement. 

Due to the importance of symptoms in patients with aortic regurgitation, you must let your Healthcare Professional know if you develop symptoms in-between clinic appointments. This is especially important if you have severe aortic regurgitation.

Is aortic regurgitation associated with any other conditions?

Some patients with aortic regurgitation also have abnormalities of the aorta (the main blood vessel leaving the heart). If this is the case your Healthcare Professional may advise medication to keep your blood pressure controlled.

What tests will I need?

Most people with aortic regurgitation will have an echocardiogram (echo or cardiac ultrasound) and an ECG (electrocardiogram). Other tests that you may be sent for include a Cardiac MRI, a CT scan, a transoesophageal echocardiogram and an exercise tolerance test.

Do I need to change my lifestyle if I have aortic regurgitation?

As with any type of heart disease, it is important that you follow a healthy diet and keep your weight within a normal range. If you smoke it is advisable that you stop. Your GP can guide you to support available to help you stop smoking.

Most patients with aortic regurgitation will be encouraged to take regular gentle exercise but you should check this with your Healthcare Professional.

If you have a stretch/enlargement of the aorta (the main blood vessel exiting the heart) you are advised to avoid heavy lifting. A good guide is to avoid lifting objects so heavy that they make you strain or go red in the face. 

If you are planning to get pregnant, you should discuss this with your Healthcare Professional first and let them know immediately if you become pregnant. 

It is very important that you keep your teeth in good condition to prevent a rare heart valve infection called endocarditis. You should visit your dentist regularly for dental checks and seek attention urgently from your dentist if you get toothache or a dental infection. It is important that you mention to your dentist that you have aortic regurgitation (heart valve disease). In the past, many patients were advised to have antibiotics prior to dental treatment. This is no longer the case for most patients with aortic regurgitation but more information can be seen in the section 'caring for your heart and preventing infection'. 

What are the symptoms of aortic regurgitation?

If you experience any new symptoms in between clinic appointments it is important that you let your Healthcare Professional know.

Important symptoms to be aware of:

  • Increasing shortness of breath (especially on exertion or when lying flat in bed)

  • Severe or increasing ankle swelling

  • Exertional chest pain, discomfort or heaviness

  • Palpitations (rapid or irregular heartbeat)

  • Difficulty exercising (not being able to do as much for as long)

  • Blackouts

Mitral regurgitation

What is the mitral valve?

The mitral valve is a valve situated on the left hand side of the heart. It is a one way valve that allows blood to move from the left atrium (top chamber of the heart) to the left ventricle (bottom chamber of the heart, the main pump or engine of the heart). 

What is mitral regurgitation?

Mitral regurgitation is a condition where the one way valve is not working correctly. When the main pumping chamber (left ventricle) contracts, all of the blood should leave the heart into the aorta. In mitral regurgitation, the one way mitral valve is unable to close tightly and blood leaks back into the left atrium (top chamber of the heart). When the heart is listened to with a stethoscope, the abnormal blood flow results in an abnormal sound known as a heart murmur. 

What causes mitral regurgitation?

There are many different causes of mitral regurgitation, these include

  • Valve degeneration (wear and tear)

  • Mitral valve prolapse (floppy mitral valve)

  • Damage to the heart valve following heart valve infection (endocarditis)

  • Congenital disorders (people born with an abnormal heart valve)

  • Heart failure / following a heart attack (known a functional or ischaemic mitral regurgitation)

  • Hypertrophic cardiomyopathy (a genetic condition causing thickening of the heart muscle)

What are the symptoms of mitral regurgitation?

Most people with mitral regurgitation will not experience any symptoms. If the regurgitation (leak) is severe, then symptoms such as exertional shortness of breath, swollen ankles and tiredness can occur. 

Palpitations (a feeling of your heart beating rapidly or erratically) can also be experienced in patients with mitral regurgitation. 

If you experience any of the above symptoms you should contact your Healthcare Professional.

What tests will I need if I have mitral regurgitation?

Most people with moderate or severe mitral regurgitation will have a regular echocardiogram (echo or cardiac ultrasound) and Electrocardiogram (ECG). Other tests including cardiac monitor, exercise testing, trans-oesophageal echocardiogram or coronary angiogram may be required.

What are the treatment options available?

Most people with mitral regurgitation will not require any treatment and will just require regular monitoring of their condition. 

If the mitral valve is severely leaky (severe mitral regurgitation) and either you develop symptoms or the heart is struggling (becomes severely stretched or the pump starts to deteriorate) then you may be referred for mitral valve intervention.

What does mitral valve intervention involve?

A series of tests before you are referred for mitral valve intervention will help decide which type of intervention you are suitable for. These tests may include coronary angiography (also known as cardiac catheterisation) and trans-oesophageal echocardiography (TOE).

Once all your test are complete your case may be discussed at a multi-disciplinary team meeting of the heart valve team.

Types of mitral intervention include surgical mitral valve repair, surgical mitral valve replacement and transcatheter mitral valve repair (Mitraclip).

What is surgical mitral valve repair?

This is a technique performed under general anaesthetic where you are attached to a heart-lung machine (cardiopulmonary bypass machine). The surgeon will then gain access to your heart via the breastbone (sternotomy approach) or by a smaller incision in the side of your chest (minimal access approach / minimally invasive surgery). Your heart valve is then repaired using Gore-tex chords (ropes) and the original valve refashioned (repaired) via various surgical techniques. At the end of the procedure, a synthetic 'ring' is sutured around the original valve to complete the procedure. After the operation you typically spend 1-2 days in the Intensive Care Unit and 7-10 days on the ward to recover. At Wythenshawe Hospital we have several dedicated mitral valve surgeons who perform mitral valve repair operations very frequently with excellent outcomes. 

What is surgical valve replacement?

This is performed when your valve is deemed unsuitable for valve repair, or if during an valve repair operation the valve repair is technically difficult. This is a technique performed under general anaesthetic where you are attached to a heart-lung machine (cardiopulmonary bypass machine). The surgeon will then gain access to your heart via the breastbone (sternotomy approach). Your mitral valve is removed by the surgeon (with the support structures below the valve usually preserved, known as chordal sparing). A new valve is then sewn in its' place. This valve can be either bioprosthetic (also known as a tissue valve) or mechanical (sometimes known as metal - although in fact they are carbon!). After the operation you typically spend 1-2 days in the Intensive Care Unit and 7-10 days on the ward to recover.

What is the difference between a bioprosthetic and mechanical valve replacement?

A bioprosthetic valve is also known as a tissue valve as it is typically made from pig or cow tissue. As these are 'natural' materials, they function very well as heart valves and are accepted by the body. Usually there is no requirements for long term thinning of the blood (warfarin) when you have this type of heart valve and therefore they are often used as valve replacements. The downside to this type of valve is that they can degenerate over time. The rate of degeneration varies according to valve type, valve positiona and age at the time of implant (valves degenerate more rapidly in younger patients). Some bioprosthetic (tissue) valves may last up to 20 years but generally we advise that they will last 10-15 years prior to them starting to fail. For this reason their use is usually restricted to older patients. 

Mechanical heart valves are made of carbon. Due to their durable construction, they usually last a lifetime and therefore they are often the valve type of choice in younger patients. The downside of this type of valve is that they can attract small blood clots onto their surface. For this reason, when you have a mechanical heart valve you need to take warfarin to prevent these blood clots from forming and being thrown off around the body (the most worrying place these clots can travel is to the brain causing a stroke). Newer blood thinners (known as DOACs or NOACs eg apixaban, rivaroaxaban, dabigatran and edoxaban) do not work well enough in preventing these blood clots and therefore cannot be used instead of warfarin. Warfarin requires regular blood tests (INR readings) to ensure that the blood thinning is within the correct range and therefore is a less attractive option for some patients. Furthermore, there is a small risk of bleeding complications when taking warfarin, especially if you have hobbies or a job where you may be subject to a head injury. 

Your cardiologist and heart surgeon will talk to you about the pros and cons of each type of valve replacement.

What is trans-catheter mitral valve repair (often known as Mitraclip)?

Trans-catheter mitral valve repair is a keyhole procedure performed via the vein in your leg. Under general anaesthetic, a tube (catheter) is inserted into the vein in the groin. Under guidance from a transoesophageal echocardiogram (TOE, ultrasound probe placed in the gullet), a 'clip device' is entered into the heart. It crosses from the venous (blue blood) side of the heart into the arterial (red blood, left side of the heart) via a membrane in the top chamber of the heart. The clip is then attached to the mitral valve to bring the two mitral valve leaflets together and reduce the amount of leak on the mitral valve. 

 

The procedure is sometimes known as a 'Mitraclip' procedure as this was the first brand of clip to be developed but there are now other 'brands' on the market and the type of clip most suitable to your condition will be chosen by the heart valve team.

Transcatheter mitral valve intervention is usually considered in patients that are not suitable for surgical mitral valve repair or replacement surgery.

Wythenshawe Hospital is one of the few centres in the UK that is able to offer trans-catheter mitral valve repair. 

Do I need to change my lifestyle if I have mitral regurgitation?

As with any type of heart disease, it is important that you follow a healthy diet and keep your weight within a normal range. If you smoke it is advisable that you stop. Your GP can guide you to support available to help you stop smoking.

Most patients with mitral regurgitation will be encouraged to take regular gentle exercise but you should check this with your Healthcare Professional.

If you are planning to get pregnant, you should discuss this with your Healthcare Professional first and let them know immediately if you become pregnant. 

It is very important that you keep your teeth in good condition to prevent a rare heart valve infection called endocarditis. You should visit your dentist regularly for dental checks and seek attention urgently from your dentist if you get toothache or a dental infection. It is important that you mention to your dentist that you have mitral regurgitation (heart valve disease). In the past, many patients were advised to have antibiotics prior to dental treatment. This is no longer the case for most patients with mitral regurgitation but more information can be seen in the section 'caring for your heart and preventing infection'. 

Mitral valve prolapse

What is the mitral valve?

The mitral valve is a valve situated on the left hand side of the heart. It is a one way valve that allows blood to move from the left atrium (top chamber of the heart) to the left ventricle (bottom chamber of the heart, the main pump or engine of the heart). 

What is mitral valve prolapse?

Mitral valve prolapse is a condition where one or two of the leaflets of the mitral valve become floppy and instead of closing properly they billow (bulge) into the left atrium (top chamber of the heart). It is sometimes known as Barlow's valve / syndrome. It is one of the commonest valve abnormalities and effects around 1 in 50 of the population and is more common in females. 

Sometimes, as well as the valve flopping back into the top chamber of the ehart when the heart muscle pumps, the valve also becomes leaky (known as mitral regurgitation) and blood flows back into the top chamber when the main pump contracts.

What causes mitral valve prolapse?

Most causes of mitral valve prolapse are simply due to valve degeneration (wear and tear). In a few people, they can be due to conditions which affect joint and cartilage elasticity such as Marfans and Ehlers-Danlos syndrome.

How is mitral valve prolapse diagnosed?

Mitral valve prolapse is diagnosed following an echocardiogram (echo ro cardiac ultrasound). Most people who are diagnosed with mitral valve prolapse find out they have the condition by chance when they have an echocardiogram for other reasons. In other cases, your Healthcare Professional may hear a heart mirmur when they listen with a stetoscope prompting an echocardiogram. Not all people with mitral valve prolapse will have a heart murmur.

Some people with mitral prolapse experience palpitations and may have an echocardiogram arranged due to this.