Wednesday, October 12, 2011

Valvular Heart Disease

About valvular heart disease
Valvular heart disease is the name given to any dysfunction or abnormality of one or more of the heart’s four valves, including the mitral valve and aortic valve on the left side, and the tricuspid valve and pulmonic valve on the right side. In a normally functioning heart, the four valves (flaps made of tissue) keep blood flowing in one direction and only at the right time. They act as gates that swing open to allow blood to flow through and then tightly shut until the next cycle begins.

According to the American Heart Association’s 2006 Heart and Stroke Statistical Update, valvular heart disease is responsible for nearly 20,000 deaths each year in the United States and is a contributing factor in about 42,000 deaths. The majority of these cases involve disorders of the aortic valve (63 percent) and the mitral valve (14 percent). Deaths due to pulmonic and tricuspid valve disorders are rarer (0.06 percent and 0.01 percent, respectively).

Valvular heart disease in women may pose a greater risk of complications in pregnancy – to the mother and to the fetus. This is largely due to the normal increase in the amount of blood flow to the body from the heart (cardiac output) during pregnancy. Some heart valve conditions, like mitral valve prolapse, are not typically associated with pregnancy complications. Severe aortic stenosis, though, should be corrected before a woman becomes pregnant. Depending on the type of valve disorder, women will be advised to have regular visits to a cardiologist during the course of their pregnancy.

There are a number of types of valvular heart disease, including:

• Valvular stenosis. A condition in which there is a narrowing, stiffening, thickening, fusion or blockage of one or more valves of the heart. As a result, the defective valve can interfere with the smooth passage of blood through it. Depending on which valve is affected, the diagnosis may be aortic stenosis, mitral stenosis, pulmonic stenosis or tricuspid stenosis.

• Valvular regurgitation. A condition in which blood leaks back in the wrong direction because one or more of the heart’s valves is closing improperly. The nature and severity of the leakage, in turn, may keep the heart from circulating an adequate amount of blood through the defective valve. Depending on which valve is affected, the diagnosis may be aortic regurgitation, mitral regurgitation, pulmonary regurgitation or
tricuspid regurgitation.

• Atresia of one of the valves. A serious condition in which one of the valves has failed to develop properly and is completely closed at birth. Depending on which valve is affected, the diagnosis may be aortic atresia, mitral atresia, pulmonary atresia or tricuspid atresia.

• Mitral valve prolapse. A common and rarely serious condition in which the two flaps of the mitral valve (located between the left atrium and the left ventricle cannot close properly, and may result in blood leaking back into the left atrium (mitral valve regurgitation). It is due to either one (or both) of the flaps being too large, or because the muscle “hinges” of the flaps are too long.
valvular regurgitation 
People who slowly develop valvular heart disease may not notice any symptoms because the heart is given time to adjust. However, valve disease that develops suddenly can cause a variety of symptoms including palpitations, chest pain and edema (swelling) in the ankles, feet or abdomen. Weakness, dizziness and rapid weight gain may also occur. The severity of a patient’s symptoms does not always reflect the severity of their condition. Patients with severe valvular heart disease may have no symptoms and those with severe symptoms only have a minor valve problem that does not require treatment. As a general rule, patients experiencing any new symptoms, or symptoms that are more frequent or severe, should contact a physician.
The diagnosis of valvular heart disease is usually performed by one of the following tests:
• Physical examination may reveal a murmur, evidence of heart enlargement and fluids within the lungs.
• An electrocardiogram (EKG) may reveal arrhythmias and chamber enlargement.
• Echocardiography and a Doppler ultrasound are the most widely used methods, and are very useful in assessment of presence and severity of valve disease.
• MRI can provide clear three-dimensional images of the heart and its valves.
Treatment for valvular heart disease depends on the type and severity of the diagnosis. People with minor valve problems may not require treatment. Those with more serious disorders can often be treated successfully with medications such as the following:
• ACE inhibitors. Widen blood vessels, lower blood pressure and decrease the workload of the heart (in the case of valvular regurgitation).
• Antiarrhythmics. Maintain a regular heartbeat and slow rapid heart rhythms. Therefore, the heart beats less frequently but more effectively, pumping more blood through the body.
• Antibiotics. Help prevent or treat infection.
• Anticoagulants. Help prevent the formation of blood clots.
• Diuretics. Lower excess fluid levels in the body.
• Inotropes. Increase the force of the heart’s contractions.
If medications are not successful or a valve condition worsens interventional procedures and/or surgery may be necessary. These may include heart valve repair or replacement. A heart valve repair may be done by one of the following procedures:
• Percutaneous balloon valvuloplasty. A nonsurgical, catheter-based procedure to treat valvular stenosis.
• Valvulotomy. A type of open-heart surgery in which the surgeon cuts into a valve to repair valvular damage. One such type is a commissurotomy, a procedure in which narrowed valve leaflets are widened by carefully opening the fused leaflets or commissures with a scalpel. This procedure is mostly used to correct mitral stenosis.
• Minimally invasive heart valve surgery. A surgical repair of a defective heart valve performed through a small incision (3.5 inches) and partial removal of the upper breastbone (sternum) that involves less risk, fewer complications, less pain, less bleeding and faster recovery by the patient.
If heart valve repair is not an option, a heart valve replacement could be performed. This is an open–heart surgery in which a biological or mechanical valve is used to replace a defective heart valve.
Ongoing research on valvular heart disease
Biological heart valves last about 10 years before they start to fail due to tissue disintegration. Mechanical valves, which are made from metal or other man-made (synthetic) materials, are designed to last a lifetime. They are often used if all other factors are equal. However, mechanical valves carry a higher risk of blood clots, so patients with mechanical valves must take anticoagulants for life.
Researchers are continually exploring possible causes and treatments for heart valve diseases as well as the long-term effects of those treatments. Recent findings include:
• Stem cell research is being applied to congenital heart disease. Found in bone marrow, lymphatic tissue and embryos, immature stem cells can differentiate into specific, specialized body cells, including cardiac muscle cells. In animal studies, for example, bone marrow stem cells have evolved into cardiac cells after they were injected into damaged heart muscle. These results, however, have yet to be duplicated in human beings, and any benefits from stem cell therapy may be years away.
• Robotically-assisted surgery is showing benefit for both simple and complex mitral valve repairs. Robotic surgery involves voice-activated robotic “hands” at the operating table, with the cardiac surgeon manipulating the hand controls. The surgeon views the procedure through an endoscope, a slim optical tube with an attached camera positioned inside the chest. Advantages of this and similar procedures are small incisions, less surgical trauma and a shorter operative and recovery period.
• Cells from a patient’s own blood vessels can be “grown” over biological valves taken from pigs or human cadavers. Scientists remove the cells from the biological valve, leaving only elastic tissue that retains the valve’s shape. The patient’s cultured cells are then grown over the elastic tissue. After about one year, the new valve is implanted into the patient. It has been shown that this procedure resulted in fewer post-operative complications (e.g., fever, hospital stay) compared to conventional valve replacement.
• Surgeons are exploring heart valve replacement without the need for open-heart surgery. Typically, diseased or defective valves are replaced with an artificial valve or a tissue valve (from a pig or cow). A new, less invasive procedure, known as percutaneous transcatheter heart valve implantation, involves the use of balloon catheters and large stents introduced through a puncture in the skin (in the groin area, near the femoral vein). The new heart valve is transported via the stent to the site,
where the stent is then expanded to implant the valve. For patients not able to undergo open-heart surgery, due to age and/or physical condition, percutaneous heart valve implantation may impact significantly on survival and quality of life.
• Studies are evaluating whether medical (drug) therapy can offer improvement in aortic stenosis. Stenosis can develop due to a buildup of calcium, causing decreased mobility in the aortic valve. This calcium buildup is a form of atherosclerosis. Statins, a type of cholesterol-reducing drug, have shown to be effective in reducing calcium deposits in and around the heart. Therefore, there is interest in this class of drugs for
the treatment of aortic stenosis. In early studies, researchers found that, while lower cholesterol levels did not impact on aortic stenosis, statins slowed its progression. This could be due to its effect and reducing C-reactive protein and overall inflammation around the heart – another cause of atherosclerosis.
• Treating calcification of the aortic valve with ACE inhibitors is also being explored. These are medications that block the effects of angiotensin-converting enzymes, which normally have a role in blood pressure. It is believed that angiotensin-converting enzyme (ACE) is transported by low-density lipoproteins (LDLs, so–called “bad” cholesterol) into areas damaged by plaque, contributing to calcification.
Questions for your doctor
Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to valvular heart disease:
1. Do I have any type of Valvular Heart Disease?
2. Which of my valves is affected? What does this mean?
3. Am I taking any medications that may be causing this condition? Could an underlying medical problem be responsible?
4. Do you recommend any surgeries or medications to correct my problem? Why do you feel this is the best course of action?
5. How invasive would corrective surgery be? Why is/isn't this a good option for me?
6. Are there any recent treatment breakthroughs in this area that I may benefit from?
7. Are there any lifestyle changes I can make that could improve my condition?
8. Are there any activities I should not engage in?
9. Does Valvular Heart Disease prevent me from becoming pregnant? Could it cause complications if I am already pregnant?

1 comments:

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