Valvular heart disease: treatment options
What is valvular heart disease?
We all have four valves in our heart. The left-sided valves are the most important – the mitral and aortic valves. If they start to deteriorate, you may have several symptoms, including shortness of breath, due to the valves not working properly.
The valves might not work properly, either because they have become narrow, or they have become leaky – or both. This can be a congenital problem, or it can develop as the patient grows older, or as the valves become calcified from wear and tear.
In general, patients see me because they have either shortness of breath, or because someone has listened to their heart and could hear a murmur.
A murmur is usually turbulent fluid around the valves – either because the valve is leaky or because there is fast flow through a narrowed valve. Imagine if you are holding a hose and you’re watering; if you press the hose and you make the exit narrower, the water will go further. That is what you can hear: the fast flow when the valve is narrowed.
We start by examining the patient and measuring their blood pressure. Listening with the stethoscope can often tell us exactly which valve is malfunctioning. We can then take a picture and video of the valves by ultrasound or echocardiography.
Sometimes it is difficult to be sure, so we might arrange an MRI scan of the heart to look at the valves. We often follow up patients regularly, if they have this problem, depending how bad the valves are.
We have certain criteria to guide us when we need to intervene – either to replace or repair the valves. For example, if the aortic valve has narrowed; we wait until it reaches a certain level and we use several measures, such as the gradient across the valve or the area of the valve.
Only when aortic valve narrowing reaches the right level – and only if the patient has symptoms – do we consider aortic valve replacement. The valve replacement for the aortic valve, could be an open operation or a percutaneous. We generally reserve the percutaneous option (TAVI or TAVR) for older people and it is a new technique. If the valve is leaky, we cannot really do it percutaneously; it must be an open operation to replace a valve – either with a tissue or a metallic valve.
Now, the mitral valve is slightly different. Though rare, a narrowing can be caused by rheumatic fever, which is scarcely seen in this country. The patient then may be short of breath.
The most common problem with the mitral valve is the valve leaking, or mitral regurgitation. This can be congenital, or it could be that the valve was slightly abnormal from birth and it gradually gets worse. It may also be due to the patient having a heart attack, which in turn damages the valve, or it could be that the heart is dilating, or stretching the valve.
Either way, patients can become short of breath, but the trick with the mitral valve is to operate on patients before they become symptomatic. We used to wait for people to have symptoms, but then we found that after we performed the operation, only 50% of them improved and 50% deteriorated badly.
So, what do we do with patients who have mitral regurgitation? We follow up regularly, with ultrasounds, to measure the size of the heart.
We must move quickly if we think the valve is leaking significantly – and we may repeat the scan once a year, following up with the patient to ensure everything is alright.
A mitral valve problem quite often predisposes to arrhythmias as well, a lot of patients develop AF (atrial fibrillation) and have a slight risk of stroke as a result.
I would look after the patient. For example, should they have more new symptoms, I would see them at short notice, and if they do not have any new symptoms, I would see them once a year.
At the point where I decide that something needs to be done, I usually arrange for an angiogram, to make sure that their coronary arteries are okay, and we will then refer them for the operation.
We usually refer them to London as this cannot be done in our Reading practice; we have several options of surgeons.
After the procedure, the patient visits me for a follow up. If it is a metallic valve, I tend to see them once or twice, as in general, the valve will not deteriorate. If they have a tissue valve, they will have a regular follow up with a scan every year.