Heart Valve Disease

Your heart has four valves that act like one-way doors, opening and closing with each heartbeat to ensure blood flows in the right direction through your heart’s chambers. When these valves malfunction—either failing to open fully or not closing completely—your heart must work harder to pump blood effectively. Valve problems develop in various ways, from birth defects present since childhood to gradual deterioration with aging or damage from infections. Some people live for years with mild valve disease never knowing anything is wrong, while others develop severe symptoms requiring surgical repair or replacement.

Overview

Heart valve disease occurs when one or more of your heart’s four valves doesn’t work properly. These valves—the mitral, tricuspid, aortic, and pulmonary valves—open and close with each heartbeat, ensuring blood flows forward through your heart’s chambers and out to your body and lungs.

The mitral valve sits between your left atrium and left ventricle, the heart’s main pumping chamber. The aortic valve lies between the left ventricle and the aorta, your body’s main artery. These left-sided valves handle high-pressure blood flow and are most commonly affected by disease. The tricuspid valve sits between the right atrium and right ventricle, while the pulmonary valve lies between the right ventricle and pulmonary artery carrying blood to your lungs.

Valve problems fall into two main categories. Stenosis means the valve doesn’t open fully, becoming narrowed or stiff. Blood flow through the restricted opening requires higher pressure, forcing the heart to work harder. Regurgitation, also called insufficiency or incompetence, means the valve doesn’t close completely. Blood leaks backward with each heartbeat, reducing forward flow and forcing the heart to pump the same blood multiple times.

Some people have both stenosis and regurgitation of the same valve. The severity ranges from mild, where the valve problem causes minimal impact and might never require treatment, to severe, where heart function is significantly impaired and intervention is necessary.

Valve disease can be present from birth—congenital valve disease—or develop later in life—acquired valve disease. The bicuspid aortic valve, where the aortic valve has two leaflets instead of the normal three, is the most common congenital heart defect, affecting about 1-2% of the population.

The condition becomes more common with age. Degenerative valve disease from wear and tear affects millions of older adults. Calcification, where calcium deposits stiffen valve leaflets, is particularly common in the aortic valve.

Heart valve disease ranges from an incidental finding on examination causing no symptoms to severe disease causing heart failure, dangerous arrhythmias, or sudden death. Many people live normal lifespans with mild valve disease, while severe disease requires surgical intervention.

Causes

Heart valve disease develops through various mechanisms depending on which valve is affected and the type of problem.

• Degenerative or age-related changes are the most common cause in developed countries. Over decades, valve leaflets undergo wear and tear. The aortic valve is particularly susceptible—calcium deposits accumulate, making leaflets thick and stiff, causing stenosis. Mitral valve leaflets can become floppy and stretch, causing regurgitation. These changes accelerate after age 60-65, though they can begin earlier.
• Bicuspid aortic valve is a congenital abnormality present in 1-2% of people. Instead of three leaflets, the valve has only two, which function less efficiently and wear out faster. People with bicuspid aortic valves typically develop stenosis or regurgitation in their 40s, 50s, or 60s—much younger than those with normal three-leaflet valves.
• Rheumatic heart disease, though now rare in developed countries, remains a major cause globally. It results from rheumatic fever, a complication of untreated strep throat that occurs mainly in childhood. The immune response damages heart valves, particularly the mitral valve, causing both stenosis and regurgitation. Damage often doesn’t become apparent until decades after the initial infection.
• Infective endocarditis is a serious infection of the heart’s inner lining and valves. Bacteria entering the bloodstream—from dental procedures, IV drug use, or infected catheters—can settle on valves, destroying tissue and causing severe regurgitation. This medical emergency requires prolonged IV antibiotics and often surgery.
• High blood pressure over many years can cause the aortic valve to deteriorate faster and contributes to aortic root dilation, which can cause aortic regurgitation.
• Connective tissue disorders including Marfan syndrome and Ehlers-Danlos syndrome affect the structural proteins in valve tissue, causing valves to become weak, floppy, or prone to tearing.
• Previous heart attacks can damage the muscles supporting the mitral valve, causing it to leak.
• Mitral valve prolapse, where mitral valve leaflets bulge back into the left atrium during contraction, affects about 2-3% of the population. Most cases are mild and never cause problems, but severe prolapse can progress to significant regurgitation requiring treatment.
• Carcinoid syndrome, a rare condition involving hormone-secreting tumors, can damage right-sided valves.
• Radiation therapy to the chest for cancer treatment can damage valves years or decades later.
• Certain medications including some appetite suppressants and migraine drugs have been associated with valve damage, though this is uncommon.
• Autoimmune diseases, particularly lupus and rheumatoid arthritis, can affect heart valves.

Symptoms

Many people with mild to moderate valve disease have no symptoms for years or even decades. Symptoms typically develop gradually as valve dysfunction worsens, though sometimes they appear suddenly.

• Shortness of breath is the most common symptom across all valve diseases. Initially noticed only during exertion—climbing stairs, walking uphill, or exercising—breathlessness progressively worsens. As disease advances, less activity triggers symptoms, and eventually breathlessness occurs at rest or when lying flat. Many people with severe valve disease sleep propped up on multiple pillows because lying flat causes fluid to redistribute to the lungs.
• Fatigue and reduced exercise tolerance develop as the heart can’t pump enough blood to meet your body’s demands. Activities you once did easily become exhausting. This profound tiredness doesn’t improve with rest.
• Swelling in the ankles, feet, and legs indicates fluid retention from heart failure. This edema is typically worse at the end of the day and improves somewhat overnight when legs are elevated.
• Palpitations or awareness of your heartbeat occur when valve disease leads to arrhythmias. Atrial fibrillation is particularly common with mitral valve disease as the left atrium enlarges.
• Chest discomfort or pressure can occur with aortic stenosis, particularly during exertion. The narrowed valve prevents adequate blood flow to meet the heart’s own oxygen needs during activity.
• Dizziness or fainting, called syncope, is concerning when it occurs with aortic stenosis. These symptoms suggest severe narrowing and indicate high risk for sudden death. Any fainting episode in someone with known aortic stenosis requires immediate medical attention.
• Rapid weight gain from fluid retention signals worsening heart failure from valve disease.
• Some people notice their heartbeat in their neck or head due to the forceful pulse from regurgitant valves, particularly aortic regurgitation.
• Heart murmurs—abnormal sounds heard through a stethoscope—are often the first sign of valve disease discovered during routine examinations, sometimes in people with no symptoms whatsoever.

The progression from no symptoms to severe symptoms varies enormously. Some valve diseases progress over decades, while others worsen relatively quickly.

Diagnosis

Diagnosing heart valve disease involves detecting abnormal heart sounds, determining which valve is affected and how severely, and assessing impact on heart function.

• Physical examination often reveals the first clue. Your doctor listens to your heart with a stethoscope, detecting heart murmurs—whooshing sounds created by turbulent blood flow through abnormal valves. The murmur’s characteristics—timing, location, loudness, and how it changes with breathing or position—provide clues about which valve is affected and the type of problem. However, not all murmurs indicate serious valve disease, and not all valve problems cause audible murmurs.
• Echocardiography is the primary test for diagnosing and evaluating valve disease. This ultrasound examination visualizes valve structure and movement, shows how well leaflets open and close, measures blood flow through valves, assesses severity of stenosis or regurgitation, evaluates how the heart compensates for valve dysfunction, and measures heart chamber sizes and function.
• Transthoracic echocardiography is performed through the chest wall and is usually sufficient. Transesophageal echocardiography, where a probe is passed down the esophagus for closer images, provides superior detail when needed, particularly for the mitral valve or when planning surgery.
• Stress echocardiography combines exercise or medication-induced stress with ultrasound imaging. This helps assess how the heart responds to exertion and can reveal symptoms or problems not apparent at rest.
• Electrocardiogram records heart electrical activity, identifying arrhythmias common with valve disease and showing signs of heart chamber enlargement or strain.
• Chest X-ray shows heart size and whether fluid has accumulated in the lungs. Enlarged hearts and pulmonary congestion indicate severe valve disease or heart failure.
• Cardiac catheterization might be performed before surgery, particularly to evaluate coronary arteries. This test directly measures pressures inside heart chambers and across valves, confirming severity when other tests are unclear.
• Cardiac CT or MRI provides detailed images of heart structure, particularly useful for planning surgery or when echocardiography doesn’t provide adequate information.
• BNP or NT-proBNP blood tests measure hormones released when the heart is stressed. Elevated levels support heart failure diagnosis and help assess severity.

Treatment

Treatment depends on which valve is affected, severity of dysfunction, symptoms, and how the heart is compensating.

• Watchful waiting with regular monitoring is appropriate for mild to moderate valve disease causing no symptoms and not significantly affecting heart function. You undergo echocardiograms every 6-12 months to several years depending on severity, watching for progression. Many people live entire lifespans with mild valve disease never requiring intervention.
• Medications don’t cure valve disease but manage symptoms and complications. Diuretics reduce fluid retention and breathlessness. Blood pressure medications reduce workload on certain valve problems. Medications control heart rate if atrial fibrillation develops. Blood thinners prevent blood clots and stroke in people with certain valve diseases or atrial fibrillation.
• Antibiotics before dental and certain medical procedures prevent infective endocarditis in people with specific high-risk valve problems. However, this prophylaxis is now recommended for fewer conditions than previously.
• Surgery becomes necessary when valve disease is severe and causing symptoms, when heart function is deteriorating, or when certain complications develop. Two surgical approaches exist—valve repair and valve replacement.
• Valve repair, particularly for the mitral valve, is preferred when possible. The surgeon fixes the damaged valve, preserving your native tissue. Repair techniques include removing excess tissue, tightening or reshaping the valve ring with an annuloplasty ring, or repairing torn portions. Mitral valve repair has excellent long-term results, with most repaired valves lasting decades. Repair generally has lower complication rates than replacement and doesn’t require lifelong blood thinners.
• Valve replacement becomes necessary when repair isn’t possible or won’t be durable. The diseased valve is removed and replaced with a prosthetic valve. Two types exist: mechanical valves made of metal and carbon last a lifetime but require lifelong blood thinners to prevent blood clots; biological valves made from animal tissue (usually cow or pig) or human donor tissue don’t require lifelong blood thinners but gradually deteriorate, typically lasting 10-20 years before requiring replacement.
• Choosing between mechanical and biological valves involves weighing lifelong blood thinners and their bleeding risk against the likelihood of needing repeat surgery when biological valves wear out. Younger patients often receive mechanical valves to avoid multiple surgeries over their lifetimes. Older patients typically receive biological valves since the valves will likely outlast them, avoiding lifelong blood thinners. Individual circumstances including lifestyle, preferences, and other health conditions influence decisions.
• Traditional valve surgery requires opening the chest through the breastbone. Recovery takes 6-8 weeks.
• Minimally invasive approaches use smaller incisions, reducing recovery time to 3-4 weeks. Not all patients or valve problems are suitable for minimally invasive surgery.
• Transcatheter procedures, particularly transcatheter aortic valve replacement (TAVR), allow valve replacement without open-heart surgery. A catheter threads through blood vessels, usually from the groin, to deliver a new valve inside the old diseased valve. TAVR is now approved for people of all surgical risk levels with aortic stenosis and has transformed treatment, particularly for elderly or high-risk patients. Recovery is much faster than traditional surgery. Similar transcatheter approaches are being developed for mitral and tricuspid valves.

What Happens If Left Untreated

Consequences of untreated severe valve disease are serious and progressive.

• Heart failure develops as the heart weakens from years of working harder to compensate for valve dysfunction. Symptoms progressively worsen until even minimal activity causes severe breathlessness. Quality of life deteriorates dramatically as you become unable to perform basic activities.
• Arrhythmias, particularly atrial fibrillation, become more common as heart chambers enlarge from volume or pressure overload. Atrial fibrillation increases stroke risk and worsens heart failure symptoms.
• Pulmonary hypertension develops when left-sided valve disease causes pressure to back up into lung blood vessels. This added strain on the right side of the heart leads to right heart failure.
• Sudden cardiac death can occur with severe aortic stenosis, sometimes as the first manifestation of disease. This is why aortic stenosis causing symptoms or significantly narrowed valves requires prompt treatment.
• Infective endocarditis risk increases with abnormal valves. This serious infection can destroy valve tissue and requires prolonged IV antibiotics and often emergency surgery.
• Stroke risk increases, particularly with mitral valve disease and atrial fibrillation, as blood clots form in enlarged, poorly contracting chambers.
• Progressive decline is inevitable with severe untreated valve disease. Survival rates decline significantly once symptoms develop, particularly with aortic stenosis. Without treatment, median survival after symptom onset in severe aortic stenosis is only 2-3 years.
• Irreversible heart damage can occur if severe valve disease persists too long. Even after successful valve surgery, the heart might not fully recover if intervention was delayed until severe heart dysfunction developed. This is why surgery is often recommended before severe heart damage occurs, even if symptoms are still tolerable.

What to Watch For

If you have known valve disease, monitoring for worsening symptoms allows timely intervention.

• Report new or worsening shortness of breath to your doctor promptly, particularly if it occurs with less activity than before or appears at rest.
• Notify your doctor about fainting or near-fainting episodes, especially if you have aortic stenosis. These symptoms indicate severe disease requiring urgent evaluation.
• Seek medical attention for new or worsening swelling in your legs, ankles, or abdomen, which suggests developing heart failure.
• Contact your doctor about new chest pain or discomfort, particularly if it occurs with activity.
• Report new palpitations or irregular heartbeat, which might indicate atrial fibrillation or other arrhythmias.
• Watch for rapid weight gain—several pounds over days—which indicates fluid retention from worsening heart failure.
• If you develop fever, particularly if it’s persistent or accompanied by new heart murmurs or worsening symptoms, seek immediate medical attention. This could indicate infective endocarditis, a medical emergency.
• Reduced exercise tolerance beyond your baseline warrants discussion with your doctor. If you notice you can’t do activities you could manage weeks or months ago, your valve disease might be progressing.
• Don’t wait for symptoms to become severe before seeking help. Regular follow-up appointments with echocardiograms help your doctor identify when valve disease is progressing, even before you notice symptoms.

Potential Risks and Complications

Heart valve disease and its treatments carry various risks.

• The disease itself progressively damages the heart if severe and untreated. Heart failure, arrhythmias, sudden death, and stroke all become more likely as valve dysfunction worsens.
• Surgery carries inherent risks including bleeding, infection, stroke, kidney damage, and rarely death. Risk varies based on your age, overall health, and surgical urgency. Elective surgery in otherwise healthy individuals carries much lower risk than emergency surgery in very sick patients. Modern surgical outcomes are excellent, with mortality rates under 2-3% for elective valve surgery in good surgical candidates, though higher for more complex or emergency procedures.
• Mechanical valve complications include bleeding from required lifelong blood thinners, blood clots despite blood thinners, and very rarely mechanical valve failure. Blood thinner management requires regular monitoring and dose adjustments, restricting certain foods and medications that interact with warfarin.
• Biological valve deterioration is expected over 10-20 years, eventually requiring replacement. This might be another surgical procedure or potentially a valve-in-valve transcatheter procedure.
• Valve-related infections can occur with prosthetic valves, requiring prolonged antibiotics and sometimes valve replacement.
• Paravalvular leak, where blood leaks around rather than through replacement valves, occurs occasionally and might require additional procedures.
• Conduction system damage during surgery can affect the heart’s electrical pathways, sometimes requiring permanent pacemaker implantation.
• TAVR-specific complications include stroke during deployment, vascular damage at catheter insertion sites, and rarely, the new valve moving out of position.

Living with Valve Disease

If you have valve disease, certain adjustments help you stay as healthy as possible.

• Follow your doctor’s recommendations for activity. Many people with mild valve disease can exercise normally. Those with severe disease need restrictions, particularly avoiding heavy lifting or intense competitive sports. Your doctor provides specific guidance based on your valve problem and its severity.
• If you have a prosthetic valve or high-risk conditions, take antibiotics before certain dental and medical procedures to prevent endocarditis. Maintain excellent oral hygiene—brush and floss daily—to reduce bacteria entering your bloodstream from your mouth.
• If you have a mechanical valve requiring warfarin, maintain consistent vitamin K intake, monitor INR levels regularly, avoid medications that interact with warfarin without consulting your doctor, and be alert for bleeding signs.
• Watch for symptoms suggesting infection—fever, chills, night sweats, unusual fatigue, or new heart murmurs. Seek immediate medical attention if these develop.
• Wear medical alert identification indicating your valve disease or prosthetic valve. This ensures emergency personnel provide appropriate care.
• Maintain healthy lifestyle habits. Control blood pressure, don’t smoke, maintain healthy weight, exercise appropriately, and manage stress. These don’t cure valve disease but help your heart compensate and prevent additional cardiac problems.
• Stay current with regular follow-up appointments and echocardiograms. These detect progression before symptoms worsen, allowing timely intervention.
• Women with valve disease planning pregnancy should discuss this with their cardiologist and obstetrician. Some valve problems require treatment before pregnancy, and mechanical valves on warfarin pose risks to developing babies.

Key Points

• Heart valve disease ranges from mild abnormalities causing no problems to severe dysfunction requiring surgical intervention. Many people live normal lifespans with mild disease.
• Symptoms typically develop gradually as valve dysfunction worsens. Shortness of breath, fatigue, and swelling are most common. However, many people have no symptoms despite significant valve problems—this is why regular follow-up with echocardiograms is crucial.
• Echocardiography is the primary test for diagnosing and monitoring valve disease. This non-invasive test shows how valves function and how the heart compensates.
• Timing of intervention is crucial. Surgery too early means unnecessary risks and complications. Surgery too late means irreversible heart damage might occur. Your cardiologist helps determine optimal timing based on symptom severity, valve function, heart chamber sizes, and your overall condition.
• Valve repair is preferred over replacement when possible, particularly for mitral valve disease. Repaired valves typically last longer and avoid complications of prosthetic valves.
• The choice between mechanical and biological replacement valves involves weighing lifelong blood thinners against likelihood of needing repeat surgery. Age, lifestyle, and individual circumstances guide decisions.
• Transcatheter procedures, particularly TAVR for aortic stenosis, have revolutionized treatment. These less-invasive approaches provide excellent outcomes with faster recovery, making treatment possible for patients previously too sick for surgery.
• Regular follow-up is essential even after successful valve repair or replacement. Repaired valves can deteriorate over time, biological valves eventually wear out, and mechanical valves require ongoing anticoagulation monitoring.
• Prevention of infective endocarditis through good oral hygiene and appropriate antibiotic prophylaxis is important for people with certain valve problems and all prosthetic valves.
• Work closely with a cardiologist experienced in valve disease. These specialists understand when watchful waiting is appropriate, when medications help, and when intervention becomes necessary. They coordinate with cardiac surgeons to determine whether you need surgery, what type of surgery or procedure is best, and optimal timing. Modern treatments for valve disease are highly effective, with most people achieving excellent outcomes and returning to active lives even after severe disease. The key is appropriate monitoring to detect progression and timely intervention before irreversible heart damage occurs.

Reference: Heart valve diseases