Heart valve disease

Our hearts have four valves that function a bit like one-way gates. They make sure that the blood is pumped through your heart in the right direction. Oxygen-poor blood flows into the lungs, and oxygen-rich blood flows out of the lungs and into the body again.

Heart valve diseases are usually caused by damage to the heart valves over time. Doctors also call them “acquired” heart valve defects. These defects generally only arise in older people due to wear and tear. Heart valve problems in children are often present at birth (congenital) and are treated in a different way.

There are two types of heart valve disease:

• In valve stenosis, the valve flap can no longer open properly.
• In regurgitation, the heart valve can’t close properly.

If both problems occur together, it is called mixed valvular heart disease.

Mild cases of heart valve disease may go unnoticed for a long time. This is because if a heart valve is only slightly leaky or only slightly narrow, the heart can often compensate by pumping a bit harder.

Heart valve disease only becomes a problem if the heart can no longer pump enough blood into the body. But if a valve is very damaged, the blood builds up in the heart or lungs and ultimately in all of the blood vessels.

This leads to symptoms such as:

• weakness and drop in performance
• swelling (edema), particularly in the lower legs
• an irregular, fast or slow pulse
• shortness of breath and coughing, particularly at night
• chest tightness and chest pain
• fainting

In countries like Germany, wear and tear is the most common cause of heart valve disease. The heart valves may gradually become thick or stiff over time, and can then no longer move as easily.

However there are other, rarer causes for heart valve disease.

These include, for instance, acute bacterial infection of the inner lining of the heart (the endocarditis). Endocarditis can also suddenly make mild cases of heart valve disease worse.

A condition known as rheumatic fever – often following a bacterial infection elsewhere in the body – can also lead to heart valve disease. But that is rare in countries like Germany nowadays.

Sometimes the heart valves are healthy but the heart has become so big that the valves can no longer close properly. Various things can make the heart become enlarged. These include heart failure, a heart muscle inflammation, blood circulation problems in the heart muscle, long-term high alcohol consumption or metabolic diseases.

Heart valves may also no longer work properly if nearby heart muscle tissue has been damaged – for instance, due to a heart attack.

Damage to the heart valves in children however is usually hereditary.

Heart valve diseases mainly occur in older people. In most cases, either the aortic valve is too narrow or the mitral valve no longer closes properly. This makes the heart muscle have to work harder, which makes it grow thicker and the heart become enlarged. About 13 out of 100 people over the age of 75 have problems with one of these two heart valves. Men are slightly more often affected than women.

The heart can often compensate for a narrowed or leaky valve over years or even decades. But the heart muscle has to work harder. This makes it grow thicker and the heart becomes enlarged. If the heart has to work harder over a long period of time, it can’t return to its normal size and the problem gets worse.

This means that the thickened heart muscle is less elastic, the ventricles become “worn out” and the heart is weaker overall. At first this only causes noticeable symptoms during strenuous physical activities, but eventually the symptoms occur at rest too. This can lead to life-threatening heart failure (cardiac insufficiency).

Other heart conditions can make the symptoms of heart valve damage worse. The main heart conditions that have this effect are coronary heart (or artery) disease and irregular heartbeats such as atrial fibrillation. Heart attacks can also cause previous heart valve damage to suddenly become more noticeable. But heart attacks sometimes lead to acute heart failure even if none of the heart valves were damaged before.

Effects

Heart valve problems may get so bad that the heart can no longer pump enough blood around the body despite working as hard as it can. This leads to a vicious circle: because the heart no longer gets enough blood itself, it soon becomes weak. If in consequence the heart can’t pump enough oxygen-rich blood around the body, heart failure occurs.

Damaged heart valves can also lead to an irregular heartbeat (arrhythmia).

People may also develop lung problems because the blood starts building up there. This can result in high blood pressure in the lungs or a build-up of fluid in the lung tissue (pulmonary edema). Both of these conditions cause severe breathing difficulties.

Some people have a higher risk of heart valve complications due to endocarditis (inflammation of the inner layer of the heart) – for instance, if they are born with a heart valve defect or if they have already received an artificial heart valve. They may be given antibiotics as a preventive measure just before having procedures such as tooth or gum surgery. The antibiotics kill bacteria that could otherwise enter the bloodstream from the mouth and infect the inner layer of the heart.

Only rarely people need to take antibiotics for the rest of their life. This may be the case for people who have developed severe heart valve problems due to rheumatic fever. The aim of treatment with antibiotics is to prevent further episodes of rheumatic fever.

Smoking not only increases your overall risk of cardiovascular (heart and blood vessel) disease – it can also damage the heart valves. Not smoking, or to stop smoking, can also prevent heart valve problems.

Doctors can often already determine whether someone has heart valve problems by giving them a thorough physical examination and listening to their heart with a stethoscope.

If heart valve disease is suspected, an ultrasound scan of the heart (echocardiogram or “echo”) can be done to confirm the diagnosis and find out how severe the heart valve disease is. It sometimes can also make sense to do an echocardiogram from inside the food pipe. Like in an examination of the stomach (gastroscopy), this involves inserting a tube into the food pipe to examine the heart. But the tube is only pushed down far enough so that it is next to the heart.

If someone is diagnosed with heart valve disease, doctors check to see how healthy they are otherwise to find suitable treatment. The additional tests may include the following:

• an ECG (electrocardiogram) and an exercise electrocardiogram (exercise stress test)
• blood pressure measurement
• blood tests
• an X-ray examination, possibly a CT (computed tomography) or MRI scan (magnetic resonance imaging)

Cardiac catheterization may also be needed if it is thought that there are other health problems, for instance the coronary arteries possibly being too narrow.

Which treatment is needed will depend on many factors, for instance, which heart valve is damaged and how severely it is affected. Other important factors include the person’s symptoms, age, their general health and individual needs.

If heart valve disease has to be treated, there are two options:

• The faulty heart valve can be replaced with an artificial heart valve.
• The heart valve can be repaired through a surgical procedure.

The operation may be done through open heart surgery or using a catheter. Some people might have to take medication for the rest of their life after having this treatment.

Because heart valve disease doesn’t normally require urgent treatment, there is usually enough time to carefully consider the treatment options together with the doctor.

For more detailed information, such as how to treat heart valve disease, visit gesundheitsinformation.de.

Heart valve surgery in a hospital is usually followed by a cardiac rehabilitation program. This helps people to get used to physical exercise again and then gradually increase the intensity. Rehab improves their physical fitness and quality of life. Their medication is adjusted and their heart is checked regularly too.

Some people are scared of being too active after surgery in case it makes their heart problems worse again. As well as exercise, the rehab program involves having talks and exercises to help them cope better with the situation. Many people find that this helps them to develop a better feel for how far they can go.

If someone has been diagnosed with heart valve disease but it hasn’t been treated yet, knowing about it might make them feel anxious. Symptoms such as weakness and tiredness can be a particular problem for many people if they limit what they can do in everyday life.

It’s often difficult for many people to make a treatment decision. It can be helpful to discuss any questions or concerns they may have with their friends, family and doctor.

A list of questions can help to prepare for doctor’s appointments. It can be printed out and taken along. Decision aids can help too: they allow people to see their own situation more clearly, compare the pros and cons of different treatment options, and find out what’s most important to them.

After heart surgery, people have to take things easy for a while. So it is a good idea for them to talk to family and friends already before surgery about whether, when and how they could help. They can also already contact their health insurance provider before the operation to apply for assistance – for instance, household help. This type of support has to be prescribed by a doctor though.