Heart Valvular Disease

Thus these valves essentially help maintain forward flow of blood and prevent back leak. Thus, any abnormality in it, can prevent the smooth circulation of blood flow in the heart, leading to varied symptoms. Valvular stenosis is a condition where there is impaired opening of the valve, which prevents normal forward flow and valvular regurgitation is a condition where there is impaired closing of the valve, which causes leak or backflow of the blood through the valve.

We will describe these common heart valvular abnormalities and their treatment in this section

Aortic stenosis
Mitral stenosis
Mitral regurgitation
Tricuspid regurgitation
Pulmonary stenosis
Pulmonary regurgitation

Aortic Stenosis

This is a condition causing narrowing or impaired opening of the aortic valve, i.e. the valve responsible for transfer of blood from the left ventricle into the aorta. Thus there is less amount of blood going into the body in circulation. It is a common disorder in the elderly and affects 1 in 8 people over 75 years of age.

Causes

Age, more commonly in the elderly.

Bicuspid aortic valve - normally aortic valve is made up of 3 leaflets, if since birth, it is formed of 2 leaflets, it is called bicuspid valve and this is more prone for narrowing at an earlier age.

Occasionally, rheumatic heart disease.

Diagnosis

ECG s/o left ventricular strain pattern.

Echocardiogram is the gold standard in diagnosing this condition.

CT - occasionally CT is done to look at the morphology of the valve, also to assess severity of calcium on it and to assess feasibility for doing a TAVR procedure for the same.

Treatment

Medical management - Not much in terms of medications can relieve the symptoms secondary to this condition.

Surgical

TAVR or TAVI i.e. transcatheter aortic valve replacement or implantation is the preferred choice for patients having severe stenosis especially in patients older than 60 years of age. It is done like angiography through the groins arteries with minimal anaesthesia and patients can go home in 2 days time.

Surgical AVR - it is a conventional surgery i.e. open heart surgery especially done for younger patients, it could be with a metallic or tissue valve.

Complications

If untreated, it can cause worsening of symptoms, impaired quality of life, drop in the functioning of the heart pump and also predispose to sudden cardiac death.

Mitral Stenosis

This is a condition causing narrowing or impaired opening of the mitral valve, i.e. the valve responsible for transfer of blood from the left atria into the ventricle. Thus there is less amount of blood going into the body in circulation. It is a common disorder in the young and middle aged, especially in the rural parts of India.

Causes

Rheumatic - most common. This is a condition in which there is streptococcal bacterial infection at a young age and subsequently there is affection of the heart valves. In rheumatic heart disease, mitral valve is the most commonly affected valve with stenosis being predominant over regurgitation.

Occasionally congenital
Infective endocarditis

Symptoms

Shortness of breath
Palpitations
Dizziness or loss of consciousness
Easy fatigability
Swelling over the feet in later stage

Diagnosis

ECG s/o P pulmonale pattern, atrial fibrillation can also be seen on the ECG.

Echocardiogram is the gold standard in diagnosing this condition.

Treatment

Medical management - Diuretics (water tablets) and beta blockers are the main treatments for the condition.

Surgical - Balloon mitral valvotomy (BMV) is the preferred choice for patients having severe stenosis if feasible. It is done like angiography through the veins in the groins with minimal anaesthesia and patients can go home in 2 days time.

Surgical MVR - it is a conventional surgery i.e. open heart surgery if BMV is not possible. It could be with a metallic or tissue valve. Occasionally, surgeons can also prefer doing open mitral valvotomy (OMV) in some cases.

Complications

If untreated, it can cause worsening of symptoms, impaired quality of life and once right heart failure develops, it can cause steep worsening in the symptoms. If clot forms in the left atria, then can cause stroke or other embolic events.

Mitral Regurgitation

This is a condition causing leaking of the mitral valve, i.e. the valve responsible for transfer of blood from the left atria into the ventricle. Thus during the left ventricular contraction, there is backflow of blood into the atria because of the mitral valve leak.

Causes

Rheumatic - most common. This is a condition in which there is streptococcal bacterial infection at a young age and subsequently there is affection of the heart valves. In rheumatic heart disease, mitral valve is the most commonly affected valve with stenosis being predominant over regurgitation.

Secondary to left ventricular dysfunction with dilation of ventricle causing impaired closure of mitral valve.

Degenerative with mitral valve thickening
Mitral valve prolapse
Infective endocarditis
Marfan's syndrome
Occasionally congenital

Symptoms

Shortness of breath
Palpitations
Easy fatigability

Diagnosis

ECG s/o left ventricular strain pattern or P pulmonale, atrial fibrillation can also be seen on the ECG.

Echocardiogram is the gold standard in diagnosing this condition.

Sometimes TEE (transesophageal echocardiogram) is done to look more closely at the mechanism of mitral regurgitation and can plan treatment accordingly.

Treatment

Medical management - diuretics or water tablets can be given. Occasionally, rate controlling medicines can be given in some cases.

Surgical TEER (transcatheter edge to edge repair) is the preferred choice for patients having severe regurgitation if feasible, especially in elderly populations. It is done like angiography through the veins in the groins with minimal anaesthesia and patients can go home in 2 days time.

Surgical MVR - it is a conventional surgery i.e. open heart surgery if TEER is not possible. It could be with a metallic or tissue valve. Occasionally, surgeons can also prefer doing open mitral valve repair in some cases.

Complications

If untreated, it can cause worsening of symptoms, impaired quality of life and once the left ventricular function drops, it can cause steep worsening in the symptoms. If clot forms in the left atria, then can cause stroke or other embolic events.

Tricuspid Regurgitation

This is a condition causing leaking of the tricuspid valve, i.e. the valve responsible for transfer of blood from the right atria into the ventricle. Thus during the right ventricular contraction, there is backflow of blood into the atria because of the tricuspid valve leak.

Causes

Secondary to left sided valve disorders (most common)
Palpitations
Rheumatic etiology
Carcinoid
Infective endocarditis
Secondary to lung or rheumatological causes
Occasionally congenital like Ebstein's anomaly

Symptoms

Shortness of breath
Easy fatigability
Swelling over the feet and distension of abdomen and neck veins in later stages

Diagnosis

ECG s/o right ventricular strain pattern, atrial fibrillation can also be seen on the ECG.

Echocardiogram is the gold standard in diagnosing this condition.

Sometimes TEE (transesophageal echocardiogram) or cardiac CT is done to look more closely at the mechanism of tricuspid regurgitation and can plan treatment accordingly.

Treatment

Medical management - diuretics or water tablets can be given. Occasionally, rate controlling medicines can be given in some cases.

Surgical TEER (transcatheter edge to edge repair) is the preferred choice for patients having severe regurgitation if feasible, especially in elderly populations. It is done like angiography through the veins in the groins with minimal anaesthesia and patients can go home in 2 days time.

Occasionally, tricuspid valve replacement can also be done via the groins in some cases.

Implanting valves in the vena cavas can also be done to contain the regurgitation into the atria and not transmitting the overload in the abdomen and neck veins.

Surgical TVR - it is an uncommonly done surgery i.e. open heart surgery if TEER is not possible. It is usually done with a tissue valve. More often, surgeons prefer doing open tricuspid valve repair in some cases along with the treatment of other valves.

Complications

If untreated, it can cause worsening of symptoms, impaired quality of life and once the right ventricular function drops, it can cause steep worsening in the symptoms.

Pulmonary Stenosis

This is a condition causing narrowing or impaired opening of the pulmonary valve, i.e. the valve responsible for transfer of blood from the right ventricle into the pulmonary artery. Thus there is less amount of blood going into the lungs.

Causes

Congenital (most common), can occur as isolated pathology or can be a part of a broader genetic disorder like Noonans, Downs syndrome etc.

Carcinoid
Infective endocarditis

Symptoms

Easy fatigability
Shortness of breath
Swelling over the feet
Dizziness or loss of consciousness

Diagnosis

ECG s/o right ventricular strain pattern or right bundle branch block.

Echocardiogram is the gold standard in diagnosing this condition.

CT - occasionally CT is done to look at the morphology of the valve, also to assess severity of calcium on it and to assess feasibility for doing BPV procedure.

Treatment

Medical management - Not much in terms of medications can relieve the symptoms secondary to this condition.

Surgical BPV i.e. transcatheter balloon pulmonary valvotomy is the preferred choice for patients having severe stenosis. It is done like angiography through the groins with minimal anaesthesia and patients can go home in 2 days time.

Surgical pulmonary valve repair is a conventional surgery i.e. open heart surgery in exceptional cases balloon procedure is not possible.

Complications

If untreated, it can cause worsening of symptoms, impaired quality of life and also predisposes occasionally to sudden cardiac death.

Pulmonary Regurgitation

This is a condition causing leaking of the pulmonary valve, i.e. the valve responsible for transfer of blood from the right ventricle into the pulmonary artery. Thus after the right ventricular contraction, there is backflow of blood into the ventricle, when it relaxes because of the pulmonary valve leak.

How successful is percutaneous thermal ablation?

Causes

Congenital
Secondary to heart operations, most commonly post repair of Tetralogy of Fallot.
Carcinoid
Infective endocarditis

Symptoms

Easy fatigability
Dizziness or loss of consciousness
Shortness of breath

Diagnosis

ECG s/o right ventricular strain pattern and right bundle branch block.

Echocardiogram is necessary in diagnosing this condition.

CT scan is done to look at the morphology of the valve, also to assess severity of calcium on it and to assess feasibility for doing a PPVI procedure for the same.

Treatment

Medical management - Not much in terms of medications can relieve the symptoms secondary to this condition.

Surgical PPVR i.e. percutaneous pulmonary valve replacement or implantation is the preferred choice for patients having severe regurgitation. It is done like angiography through the groin’s veins with minimal anaesthesia and patients can go home in 2 days time.

Surgical pulmonary valve repair is a conventional surgery i.e. open heart surgery that can be done if percutaneous procedure is not possible.

Complications If untreated, it can cause worsening of symptoms, impaired quality of life and also predispose to sudden cardiac death.

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