Everything You Need to Know About HVD Types
What type of heart valve disease you have matters in the way you’re treated.
No one really thinks about the four valves in the heart—and why would you? Normally, these flaps of tissue act like doors, opening and closing to let blood in and out of your heart at a rate of 60 to 100 times per minute. Inside the heart are four chambers—two upper ones and two lower ones. “So the blood is flowing from the upper chamber to the lower chamber and then from the lower chamber out to the blood vessels,” says Smadar Kort, M.D., director of the Valve Center at Stony Brook University Heart Institute in Stony Brook, NY. “When the blood is supposed to flow from the upper chamber to the lower chamber, those valves, or doors, are open. And then when blood is leaving the lower chamber to the great vessels, the doors that are between the upper and the lower chamber are supposed to close. And they prevent blood from going back into the upper chamber.”
So that’s a normal heart. But all sorts of damage can happen to one or more valves so they don’t open or close properly, causing your heart to work harder and less efficiently. That’s heart valve disease, and over time it can cause an enlarged heart, heart failure, strokes, or even death. About 2.5% of Americans, or roughly 8 million people, have heart valve disease, according to the Centers for Disease Control and Prevention.
There are two main types of adult heart valve disease: stenosis and regurgitation. Each has different risk factors and causes, slightly different symptoms, and treatments. Here’s a breakdown of each.
What regurgitation is: When the valves don’t shut properly, they leak, causing blood to flow back into the chambers of the heart. Mitral valve regurgitation is the most common form (there are four of them)—named after the valve between the upper and lower left chambers. About 5.5 million Americans have this type of regurgitation, which can range from mild to severe. But the three other valves can develop leaks too.
What causes regurgitation: One of the most common causes is mitral valve prolapse, says Dr. Kort. That’s when the valve tissues are floppier than usual, which makes the mitral valve harder to close. Prolapsed valves run in families—you’re born with it but it usually doesn’t cause problems. “It actually is working fine, but because it's abnormal, the stresses of its daily work—essentially opening and closing—makes it degenerate faster than someone who has a normal valve,” explains Sarah Capano, PA-C, the coordinator for the Structural Heart Valve Clinic at Brigham and Women’s Hospital in Boston.
Other causes of regurgitation can include:
You’re born with two flaps instead of the normal three in the aortic valve. This is called bicupsid aortic valve and affects in roughly 2% of people, says Ibrahim Sultan, M.D., Associate Professor of Cardiothoracic Surgery at the University of Pittsburgh School of Medicine. That causes the valve to wear down faster than normal (which is why patients may be younger), making it more prone to leak (or stiffen).
A heart attack or uncontrolled high blood pressure can dilate the heart or a couple of its chambers, making it larger, says Dr. Kort. In turn, that “kind of holds the valve apart, and it allows for leaking around that valve,” she explains.
Atrial fibrillation is when your heart beats more quickly and irregularly than normal, and over the years that can damage the mitral valve.
Another valve problem, like aortic valve stenosis. The pressure of the blood going through the narrowed opening can affect the mitral valve and cause it to leak, says Capano.
Can you prevent it? Not if the leak is caused by a defective valve that you’ve had since birth. Otherwise, you may be able to keep your mitral valve healthy in the same way you take care of your heart—exercise, diet, not smoking (or quitting). And treating things like high-blood pressure, which can also damage the mitral valves.
What are the signs: A leaky valve won’t always lead to symptoms since the heart compensates for the problem. But the classic sign as the disease gets worse is when you’re short of breath, says Capano. At first, you may just get winded climbing stairs, but then find you have trouble breathing even when you’re walking on the sidewalk, she says.
Other signs include:
Being unable to lie on your back when you sleep or rest, says Dr. Kort. In that case, people may prefer to snooze in a recliner or propped up by pillows.
Swelling in your leg so your sock leaves lines or your shoes feel tight, says Capano. This is a sign that the valve is so leaky that the backflow of blood is going into the lungs, making them soggy, and fluid is building in another parts of your body, mainly your legs, ankles, and feet.
How it’s diagnosed: Need yet another reason to get a yearly checkup? If you have mild regurgitation, the only sign may be a heart murmur or some other abnormal sound that a doctor picks up. That leads to an an echocardiagram, an ultrasound of the heart, which usually clinches the diagnosis, says Capano. “When the valve won't close perfectly, then you see leak going backwards.” A doctor may also put you on a treadmill to see if you show signs of breathlessness or fatigue, especially if you’re not complaining of symptoms yet, says Dr. Kort.
How regurgitation is treated: If you have a mild regurgitation—you have a heart murmur but no changes to the heart and no symptoms, then a doctor will monitor you, says Capano. If the leak is severe and the symptoms are affecting your life, then doctors will perform surgery, say experts. Mitral valves are usually repairable, especially if you have mitral valve prolapse, Dr. Kort notes. There are a few ways to replace or repair:
Open heart repair or replacement. Under general anesthesia, a heart surgeon cuts open your chest and repairs the valve. Or she may take out the old valve and gives you a new one (either made of tissue or carbon). Or the surgeon can repair the valve this way too. If you’re too frail or have too many other co-existing conditions, doctors will probably advise against open heart surgery.
Transcatheter mitral repair, known as Mitraclip. “We go through the blood vessels in the groin into the heart, with big catheters with a clip on the end,” says Dr. Kort. Doctors implant the clip in the valve to close it and repair the leak. This successfully repairs roughly 90% of severe cases, according to the American Heart Association, though surgical repair may be more long-lasting.
What happens if you don’t treat regurgitation: Complications like congestive heart failure (although congestive heart failure can also cause heart valve disease, Dr. Kort points out). About half of people with untreated mitral valve regurgitation die after five years.
What stenosis is: Blood contains calcium, and over the years, calcium deposits on the valves cause them to become hard and stiff. That causes the opening where the blood flows in and out to become smaller and narrower. In aortic valve stenosis, the most common kind of stenosis, there’s less blood flowing out from the heart to the rest of the body via the main artery (known as the aorta). About 1.5 million people have aortic stenosis, and 500,000 having a severe case, according to the American College of Cardiology. You can have stenosis in the other valves—and you can have stenosis and regurgitation at the same time, though that’s not as common.
What causes stenosis: “Age is a risk factor for narrowing of valve,” says Dr. Kort. “Every time the heart beats, those valves open and close. So it happens many, many times in a span of a day and over a lifetime. So just like anything else in our body, over time there is a wear and tear phenomenon.” That’s why one in eight people over 75 have moderate to severe aortic stenosis. Other risk factors include:
If you were born with a bicuspid valve (that’s a valve with two flaps instead of the normal three), you may be prone to stenosis at a younger age (meaning in your 40s or 50s versus your 60s and 70s), since two flaps have to work harder and will deteriorate quicker than three flaps.
Heart disease, like high blood pressure and high cholesterol, as well as other conditions that can damage the heart, like diabetes and chronic kidney disease and dialysis, says Dr. Sultan—especially if they’re not well controlled.
Rheumatic fever, a non-contagious disease that can affect the heart and joints. You develop this inflammatory condition a few weeks after having strep or scarlet fever that wasn’t treated properly—both are bacterial infections that can be knocked out by antibiotics. In the past, rheumatic fever was a huge contributor to heart valve disease, but it’s no longer the leading cause in the U.S. and other Western countries.
Can you prevent it? Not if you were born with a bicupsid aortic valve. But most cases of stenosis are caused by calcium deposits. There are trace amounts of calcium in the blood, and over the course of decades, the mineral builds up on the valves, making them stiff and harder to open. But you can mitigate these effects with exercise and diet to keep other causes of heart disease at bay.
What else helps? “Being very compliant with medications and treating things like obesity, diabetes, high blood pressure and high cholesterol. All this adds up—a little bit here, a little bit there,” says Dr. Sultan.
One caveat: Not everyone gets these calcium deposits as they age. There are 90-year-olds with no signs of hardening valves and 70-year-olds who don’t smoke or have other risk factors who do, Dr. Sultan notes, adding that ongoing reseach is trying to uncover whether genetics or family history plays into the risk.
What are the signs: With mild cases of stenosis, you may not have any symptoms. But as the disease gets worse, you can feel short of breath, especially when you do any kind of physical activity. You also have less energy, and can’t walk far without taking breaks, say experts.
Other symptoms include:
Chest pain, or a heavy feeling in your chest, espeically with physical activity
Feeling dizzy or light-headed because there’s not enough oxygen-rich blood getting to your brain
Passing out, especially if you’ve exercised or been active. This is a sign of severe aortic stenosis, says Capano, and doctors would treat you immediately.
How stenosis is diagnosed: A doctor will listen to your heart (for a murmur or other unusual sounds) and take your family history. But the gold standard is the echocardiogram, which lets doctors see your valves and heart at work. Doctors are looking at the size of the opening (if it’s less than 1 cm, they consider that a severe case of aortic stenosis) as well as gauging the pressure of the blood as it tries to pass through that opening (if the pressure is above a certain level then it’s a sign of how advanced your condition is).
How it’s treated: If you don’t have symptoms and your heart hasn’t thickened or become enlarged, then doctors will monitor you by giving you an echocardiogram every year, especially if you’re younger than the average stenosis patient (who is in their 70s and 80s), says Capano.
But if the pressure of the blood passing through the narrow opening is too high (and the opening too small) and symptoms are affecting your life, then doctors will recommend surgery, says Dr. Sultan. For stenosis, aortic or mitral, that means replacement: “You have to take out the diseased valve and you have to put a new valve in, there’s no way to fix that,” says Capano. (Usually replacing the faulty valve causing stenosis will help the leaky valve too if you have both types of HVD.)
But there are options:
You can decide whether to replace the old valve with one made of cow or pig tissue or a mechanical one (made of carbon). “If you choose a tissue valve, it's only going to last you an average of 10 or 12 years, and you have to be on a blood thinner with it for a couple months,” says Capano. “And if you choose the mechanical valve, it should last you 30 plus years, but you have to be on blood thinner lifelong.” So, for instance, a person in their 50s might choose a mechanical valve, especially if they had open heart surgery.
You can have open heart surgery or a transcatheter valve replacement. During the transcatheter procedure, a catheter is snaked up to the heart via a vein inserted in the groin. “We have a valve that is mounted on one of those catheters and we actually put it inside the existing valve,” says Dr. Kort. Usually, if you’re frail, very old or have a lot of other health conditions, a doctor is going to recommend a transcatheter valve replacement instead of open heart surgery. Both types of procedures have similar success rates.
What happens if you don’t treat stenosis: If you have a severe case with symptoms, then you double your chances of dying within two years. In fact, nearly two-thirds of deaths from heart valve disease come from aortic valve diseases (mostly stenosis). But most people who go through surgery improve the quality of their lives—and live longer, too.
Stats about Heart Valve Disease: Centers for Disease Control and Prevention (2019). “Valvular Heart Disease.”
Stats for Regurgitation and Stenosis: Alliance for Aging Research (2016). “Silver Book Valve Disease.” https://www.agingresearch.org/app/uploads/2018/06/Silver-Book-Valve-Disease-VOLUME-Final.pdf
Treatment for HVD: Circulation (2020). “Heart Disease and Stroke Statistics—2020 Update: A Report From the American Heart Association.” https://www.ahajournals.org/doi/10.1161/CIR.0000000000000757
Valve Disease and Aging: Journal of Geriatric Cardiology. (2016.) “Aortic valve disease in the older adult.” https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5351823/https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5351823/