Valvular heart disease

Heart valve failure: description

The term valvular heart failure or valve vitals is an umbrella term for a leaky (insufficient) or narrowed (stenosed) heart valve. Depending on the affected heart valve and the nature of the error, different symptoms occur.

Heart valves have a very important valve function in the blood flow through the heart. They ensure that the blood can only flow in one direction. Opening and closing of the heart valves are carried out by pressure and flow of the blood.

Frequency of heart valve defects

One distinguishes congenital from acquired heart valve defects. About one in 100 newborns is born with a heart valve defect. As a result, the life expectancy of these babies is often reduced. The majority of heart valve defects affect the left half of the heart where the mitral and aortic valves are located.

The most common heart valve defect is the aortic valve stenosis in older age, usually due to calcification of the valve. It is the third most common cardiovascular disease in Germany. A total of 20,000 surgeries are performed annually due to a valve.

Anatomy: heart and blood circulation

The heart pumps blood through the body. It has four cavities (two atria and two chambers of the heart) with a total of four heart valves. The blood flows through the veins to the heart and reaches first the right atrium. From there it flows through the so-called tricuspid valve into the right ventricle. This pumps the blood into the pulmonary arteries with a strong muscle contraction through the pulmonary valve, allowing the blood in the lungs to re-oxygenate and release carbon dioxide.

After the passage of the lungs, the blood reaches the left atrium and flows through the so-called mitral valve into the left ventricle. This then pumps the blood through the aortic valve into the main artery (aorta).

Heart valve defects can thus affect the right (tricuspid and pulmonary) and / or the left (mitral and aortic) heart.

Narrowed heart valves (valve stenosis)

When the heart valve is narrowed, it no longer opens sufficiently. The blood builds up in front of the flap. If a valve leading out of the heart (pulmonary valve or aortic valve) is affected, the heart muscle has to apply more force in order to empty the ventricle against the higher flow resistance (pressure load). This enlarges the heart muscle. In the long term – and with further progression of the heart valve defect – the pumping power is nevertheless no longer sufficient and the pumping power of the heart decreases. It creates a heart failure.

The two most common heart valve stenoses are aortic valve stenosis and mitral valve stenosis. Depending on the severity, a distinction is made between low, medium or high grade heart valve stenoses.

Leaking heart valves (valvular insufficiency)

In patients whose heart valves do not close tightly, one speaks of a valve insufficiency. Despite the closed heart valve, the blood flows back into the section where the lower pressure prevails – ie during the contraction phase of the heart muscle (systole) from the ventricle into the atrium. Or during the relaxation phase of the heart muscle (diastole) from the pulmonary or aorta back to the ventricle.

Due to the back-flowing, additional blood volume (volume load), the heart chamber expands and the heart muscle thickens. As valvular insufficiency progresses, cardiac insufficiency also develops.

The aortic valve insufficiency (also: aortic insufficiency) and mitral regurgitation (mitral insufficiency) are the two most common types of heart valve insufficiency.

Herzklappenprolaps

Another form of heart valve failure is mitral valve prolapse (prolapse = incident). The closed mitral valve leaflets bulge clearly into the left atrium during contraction of the left ventricle. This heart valve defect is one of the most common heart valve changes in adults. Women are more likely to be affected by mitral valve prolapse than men.

Some patients have multiple heart valve defects simultaneously (combined heart valve failure or combined vitiation).

Heart valve failure: symptoms

The symptoms depend on the severity of the heart valve defect as well as on its location. Many heart valve defects cause no complaints for a long time and are therefore not noticed. But there are also acute heart valve defects such as mitral valve stenosis after rheumatic fever, which cause early (significant) discomfort.

The heart can compensate for many valve defects for a certain amount of time (compensate). In the long term, however, they overload the heart and can gradually lead to heart failure (heart failure). Often the heart valve defect is first noticed by the symptoms of heart failure.

Overall, heart valve failure symptoms are similar to stenosis and heart valve insufficiency. The most important signs are pressure and tightness around the sternum and fast fatigue. Even fainting fits are possible.

Heart valve failure symptoms of the left ventricle

The symptoms of heart valve defects of the left ventricle are mainly due to blood backflow into the left atrium and the pulmonary vessels. Those affected usually feel better in an upright and sitting position than when lying down.

Signs of mitral valve stenosis usually appear only when the opening of the mitral valve is approximately halved. The symptoms may be similar to chronic bronchitis. There are shortness of breath during exercise and later also at rest, coughing, fatigue and rapid fatigue in the foreground. A typical symptom of a long-standing mitral valve stenosis is also cardiac arrhythmia and striking reddish-bluish cheeks (so-called mitral cheeks) as a sign of poor oxygenation.

Typical signs of mitral valve insufficiency include respiratory distress (especially at night and when lying flat) and nocturnal cough, as well as in advanced disease cardiac arrhythmias and jugular veins (due to backflow into the lungs and into the right ventricle) and pulmonary edema. The unfavorable flow conditions can cause blood clots in the left atrium, which can enter the circulation and cause severe complications (such as strokes).

Common symptoms of aortic valve stenosis are blood pressure fluctuations and low blood pressure with dizziness to fainting. Since the coronary arteries are supplied with blood from the aorta, the increased working myocardium gets too little blood. Patients experience chest pains (angina pectoris), which can increase during exercise. In exertion, respiratory distress and sometimes muscle aches occur.

In aortic insufficiency sufferers complain of respiratory distress. One can observe a strong pulsation of the carotid artery (Corrigan sign), which can lead to an indicated nod with each heartbeat (Musset sign). Also in the area of ​​the nail beds there is an increased pulsation of the vessels (Quincke sign).

Heart valve defects symptoms of the right ventricle

Work the heart valves in the right half of the heart (pulmonary and tricuspid valve) due to heart valve defects no longer correct, threatens long-term right-sided heart failure. However, right-sided heart valve defects only lead to noticeable symptoms when they are already well advanced. The complaints arise from the stress on the right ventricle and the right atrium, which are weakened by the extra work.

As a result, the blood can no longer be pumped into the lungs in sufficient quantity and accumulates in front of the heart. This can lead to the following symptoms:

• difficulty in breathing
• fast fatigue
• Blue staining of (mucus) skin (cyanosis)
• Water retention in the legs (edema) and abdomen (ascites)
• Blood congestion in the superficial neck vessels
• Exposure-dependent pain in the chest and in the area of ​​the liver (below the right costal arch)

Heart valve defects: causes and risk factors

Heart valve defects can be either innate or acquired. The majority of heart defects is acquired.

Congenital heart valve defects

The most common congenital heart valve defects include aortic valve stenosis and pulmonary valve stenosis. Congenital heart valve defects are often more serious than acquired damage and often occur before the eighth week of pregnancy. In addition to genetic diseases are often influences during pregnancy such as rubella, drug or alcohol consumption of the mother cause of a congenital heart valve defect.

An aortic valve weakness in younger people is usually the result of a faulty valve system. This then only consists of two instead of three flap sails (so-called bicuspid flap).

Acquired heart valve defects

Wear and calcification of the heart valves can lead to increasing heart valve defects. These changes occur especially in people over the age of 65 years. The aortic valve calcifies particularly frequently. Calcifications can lead to both valve narrowing and leakage.

inflammation

Infections and inflammation of the heart muscle (myocarditis) or the heart lining (endocarditis) can also lead to heart valve defects. This is usually a heart valve insufficiency in which the enlargement or swelling of the myocardium (myocarditis) or scarred shrinkage (endocarditis) does not close the mitral or aortic valve tightly. But even the rarer heart valve defects of the right half of the heart are often caused by infection of the inner heart wall.

In addition to (mostly) bacterial pathogens also autoimmune diseases such as systemic lupus erythematosus (LE) can lead to endocarditis (Libman-Sacks endocarditis). The sexually transmitted syphilis may cause inflammation of the aorta in its late stage, which spreads to the aortic valve (syphilitic aortitis).

Rheumatic fever

Some pathogens can also trigger a heart valve defect indirectly: For example, in Rheumatoid fever, the immune system responds excessively to an infection with streptococci, a common bacterial trigger of tonsillitis. Its surface is similar to the body’s own structures – these are, so to speak, “mistaken” by the immune system with the bacterium. One speaks of a cross reaction. This can also affect the inner heart wall and the heart valves.

The rheumatic fever is particularly often attacked by the mitral valve. For prevention, streptococcal infections should be treated with antibiotics, especially in childhood.

Heart attack

Even in the wake of a heart attack can lead to a valve insufficiency: Due to the lack of oxygen, the so-called papillary muscles in the ventricle die off, where the tendon threads of the large sail flaps (mitral and tricuspid valve) begin. If you tear, the valve leaflet hanging from them is no longer held and strikes back into the forecourt during the grain traction of the ventricle. The result is an acute, high-grade leakage of the corresponding heart valve.

aortic dissection

Acute aortic valve insufficiency can also result from damage to the inner wall of the main artery, the so-called aortic dissection. The inner wall (intima) of the aorta tears and blood penetrates between its wall layers. Such aortic dissections often occur in the area of ​​the aorta close to the heart and can then deform the aortic valve so much that it no longer closes tightly.

cardiomegaly

Various diseases such as high blood pressure, heart muscle diseases, disorders of the thyroid function or severe anemia (anemia) can lead to a pathological enlargement of the heart (cardiomegaly). Since the valve leaflets do not grow, the affected heart valves are leaking.

Autoimmune diseases

Also autoimmune diseases such as Takayasu’s arteritis (inflammation of the large blood vessels) or genetic disorders of connective tissue metabolism (for example, the Marfan syndrome) can lead to heart valve defects such as aortic valve or mitral valve insufficiency.

Heart valve failure: examinations and diagnosis

The specialists for heart valve defects are cardiologists and cardio-surgeons. You may ask questions such as:

• Do you suffer from respiratory distress or heart pain under stress?
• How many stairs can you climb without a break?
• Have you had acute fever recently?
• Have you had any recent medical intervention, even with the dentist?
• Are you familiar with heart disease?
• What other diseases do you suffer from?

After that, the doctor will examine you thoroughly cardiologically. To this end, he pays attention initially to external signs of a heart valve defect, such as changes in the respiration, color and texture of the skin and possibly existing accumulations of fluid in the tissue (edema). Then he listens to the heart and lungs. Heart valve defects often cause typical heart sounds.

electrocardiogram

Heart valve defects can cause cardiac arrhythmias. For example, mitral stenosis is often associated with so-called atrial fibrillation. Such disorders can be a record of cardiac currents by an electrocardiogram (ECG). Cardiac arrhythmias, which may be sporadic over and over, may eventually expose a long-term ECG worn by the patient for at least 24 hours.

laboratory examination

Among other things, a blood test can provide indications of an active inflammatory process and also serves to determine (in) direct cardiac values, such as creatine kinase (CK) and BNP (Brain Natriuretic Peptide). Especially in case of suspected endocarditis, several blood cultures must be taken in addition, in which laboratory doctors search for bacteria. Another important blood test is blood gas analysis from capillary blood or arterial blood. Because with larger heart valve defects, the oxygen content of the blood can provide important clues.

Imaging studies

If the physical examination suspicion of a heart valve failure, so is one cardiac ultrasound (Doppler echocardiography). It can be performed either by placing the ultrasound probe on the chest or by inserting the probe into the esophagus (under short-term anesthesia) and can show not only the heart contour but also changes to the heart valves and, by Doppler technique, the strength and direction of blood flow through the heart valves do.

Some heart valve defects lead to a congestion with water retention in the lungs. This can show an X-ray examination, which also allows the assessment of the heart size and shape.

A modern examination of the heart is possible with the help of MRI technology (cardiac MRI). Another imaging technique is computer tomography

exercise testing

Both heart ultrasound examination and ECG can also be performed under physical stress (on the ergometer or through heart-stimulating medication). These examinations illustrate stress-related symptoms. Heart valve defects often show up in their early stages only under stress. Therefore, these studies help to identify and assess the severity of heart valve defects.

cardiac catheterization

With the help of a so-called cardiac catheter examination, the pressure conditions in the heart can be measured and the expression of severe heart valve defects can be determined. For this examination, under local anesthesia, a thin tube (catheter) is inserted into a groin vessel and pushed over the large abdominal and breast vessels with the (veins) or against the bloodstream (arteries) to the heart.

If a contrast agent is injected into the left ventricle (ventriculography or levocardiography), not only can the shape and function of the ventricle be shown, but also possible vitals.

Some heart valve defects can be “repaired” as part of this investigation. This is another reason why this invasive examination is usually at the end of the diagnosis – unless an acute heart disease is suspected.

Final assessment

The detailed diagnostics allows the severity grading, which is different for each heart valve. This classification is an important basis for therapy planning. Among other things, it is important to determine the ejection fraction.This value indicates in percentage terms how much of the blood that has flowed into the heart before a heartbeat is pumped out of the heart per beat. The value in healthy hearts is around 60 to 70 percent.

Heart valve failure: treatment

The heart valve error treatment plan depends on the type of heart valve defect, the valve involved, the severity, and also the general condition of the patient. Doctors also use heart function measurements to help with therapy. It must be individually weighed all factors to work out the best therapy for the individual concerned. The aim of the treatment is not only the symptom relief, but above all the improvement of the prognosis by a stabilization of the heart valve function.

In consultation with the patient, among other things, the following questions for treatment planning must be answered:

• What is the patient request?
• Is it a serious heart valve defect?
• Are symptoms associated with heart valve failure?
• How old is the patient?
• Does the benefit of therapy outweigh the risks?
• Which medical center is suitable for the procedure?

Basically, a distinction is made between medicinal, so-called interventional and surgical therapeutic approaches. If possible, an underlying condition should be treated first. This is especially true for the treatment of acute diseases (e.g., myocardial infarction), infections and autoimmune diseases.

drugs

Medications help to reduce cardiac arrhythmia, lower blood pressure, strengthen the pumping power of the heart and dilute the blood in case of risk of blood clots. Among other things, drugs that increase urine output are used to reduce the (volume) burden on the heart (diuretics). Other drugs lower the heart rate and thus reduce heart work (beta-blockers). After the use of heart valves from “foreign material” is often a drug coagulation inhibition necessary.

Endocarditis prophylaxis

In addition, in the case of a heart valve defect, it must always be borne in mind that antibiotic infection prophylaxis should be carried out before medical interventions in which there is the risk of infection and the resulting inflammation in the heart. For this reason, sufferers should inform their treating physicians that there is a (treated) heart valve defect, so that they may prescribe an antibiotic therapy. This applies in particular to dental treatments as well as examinations and treatments in the area of ​​the gastrointestinal tract.

Interventional treatment

Interventional or percutaneous procedures are understood in medical terminology to be interventions that are carried out very specifically and with little damage to the surrounding tissue. The distinction to a so-called minimally invasive procedure is not always easy. Cardiac valve failure treatments are interventional procedures that involve the use of cardiac catheters, such as those used to diagnose heart valve defects.

For example, constricted valves can be inflated with an inflatable balloon that is advanced into the heart via a inguinal vein and large vessels (balloon valvotomy or balloon valvuloplasty). Although then no major surgery is necessary, but it can come after such a “blast” to a valve weakness. Also, a folded heart valve replacement can be introduced by means of a catheter in the heart. In this method, only the use of biological heart valves is possible. However, the treatment of heart valve failure is not always possible with an interventional procedure.

surgery

Modern surgical procedures not only allow the performance of a larger, open surgery, but also the execution of minimally invasive operations (keyhole surgery). In a minimally invasive operation, the instruments are inserted through smaller incisions. Most commonly, the aortic and mitral valves are treated surgically.

Surgery may require the use of a so-called heart-lung machine. For this, the heart function is taken over by a machine during the operation. The heart can then temporarily be shut down by medication and the blood is diverted via the machine.

When should a heart valve failure not only be treated with medication?

The right time for the procedure is not always easy to determine. On the one hand, it should not be carried out too soon to avoid complications from the operation and, above all, any lifelong blood thinning that may be necessary. On the other hand, too late surgery can significantly worsen the prognosis due to heart damage already caused.

Heart valve replacement – different types

In the case of a heart valve defect, mechanical valves or bioprostheses of human or animal (cardiac components of cattle or swine valves) may be considered as valve replacement.

Metallic heart valves last a very long time. However, blood coagulation must be inhibited throughout life with special drugs, as otherwise blood clots attach to the valve, they can clog or dissolve and lead to a vascular occlusion.

In a biological valve replacement, no “blood thinning” is necessary. For this biological heart valves must be replaced after a certain time, as their durability is limited. Among other things, this may be due to the fact that the immune system recognizes and attacks the valves as a foreign body. One distinguishes biological replacement flaps from the animal (xenograft), from a deceased person (homograft) and stem cells from the affected person’s heart valves (autograft). How long such a shutter is is difficult to predict and depends on many factors.

A new and not yet established concept of heart valve replacement in a heart valve defect is the so-called tissue engineering. The idea behind this is that synthetic or biological heart valve scaffolds will be overgrown with cells of the affected person in the laboratory or after being introduced into the heart. This reduces interactions with the immune system and allows the valves to become virtually viable and vital.

Selection of a new heart valve

The balance between long life of the prosthesis and lifelong “blood thinning” must be decided individually. As a rule, biological heart valves are only used from the age of 60 due to their limited shelf life. Exceptions are women with children who do not want to prescribe “blood thinners”. Metallic heart valves are more likely to be selected in younger patients or in those who have to take “blood thinners” for other reasons.

After using a valve prosthesis, a flap passport should be issued, at least an annual check-up and endocarditis prophylaxis should always be considered. Endocarditis prophylaxis refers to the preventive use of antibiotics in treatments that carry a risk of infection. This must be taken into account especially in dental interventions.

Treatment of aortic valve insufficiency

The main goal of treatment with drugs is the reduction of heart strain. A purely medical therapy requires a close cardiac monitoring. More often, it is only performed bridging to alleviate symptoms until surgery. Aortic valve regurgitation should be treated surgically or interventionally with increasing symptoms and worsening cardiac function. The procedure should be done before any significant limitation of cardiac function.

Under certain conditions, aortic valvular insufficiency, as well as aortic valve stenosis, can be treated with the catheter technique (“TAVI”: Transaortic Valve Replacement). In a small tube to a folded replacement flap is introduced via a groin vessel through the large arteries in the heart, where the flap can be unfolded and attached.

In surgery, the aortic valve should be repaired as possible and not replaced. The flap pockets of the aortic valve can be gathered, for example. As a replacement for the aortic valves, there are biological and mechanical replacement flaps as well as the possibility of the Ross operation.

In a Ross operation, the aortic valve is replaced by the pulmonary valve. The much less loaded pulmonary valve is in turn replaced by a human donor flap. This method has the advantage that no lifelong blood dilution is necessary, the long-term function is very good and the exercise capacity is almost unlimited. Disadvantage is above all a possible malfunction of the dispenser flap. A Ross operation can only be performed by experienced specialists.

If, in addition to the aortic valve insufficiency, there is still an aneurysm of the cardiac artery close to the heart, this is generally treated simultaneously with the valve operation (Bentall operation).

mitral

First, mitral valve stenosis can be treated with medication. These can also relieve lighter symptoms. In particular, diuretics are helpful to reduce the volume burden on the narrowed mitral valve. Any existing cardiac arrhythmias should also be controlled by medication. As with aortic valve insufficiency, a mitral valve stenosis should be considered in time for symptom progression or reduction in cardiac function.

As an interventional treatment, the valve can be widened (balloon valvuloplasty) Alternatively, in the context of an open surgery, a valve repair with the goal of dissolution of the narrowing (commissureectomy) or a valve replacement can be performed.

Mitral Valve Insufficiency and Mitral Valve Prolapse

The treatment of mitral regurgitation has similar principles to mitral valve stenosis. Intervention to treat such a valvular failure should be for symptomatic and (or better) signs of impaired cardiac function.

The drug treatment is not recommended for all forms of mitral regurgitation, except for bridging. Mitral valve insufficiency also distinguishes between repair and replacement surgery.

A Mitralklappenreparatur can also be done today as an interventional procedure. In one available method, a clip (clip) to hold the valve together is inserted over a inguinal vein and inserted through the aorta into the heart. The clamp is then fixed so that it holds together the so-called sails of the mitral valve and thus compensates for the heart valve defect. In addition, a new valve can be introduced via a cardiac catheter, which is deployed in the valve area.

Even during surgery, this heart valve failure can be repaired. In the case of mitral valve insufficiency, a ring can be inserted into the valve area in order to reduce the valve opening area (ring annuloplasty). A gathering with special threads can also reduce the valve weakness. If repair is not possible, the flap can be surgically replaced.

Pulmonalklappeninsuffizienz

The rare pulmonary valve weakness is usually caused by pulmonary hypertension (pulmonary hypertension). The treatment of this heart valve defect is therefore by lowering the high pressure in the blood vessels of the lungs. Since pulmonary valve insufficiency usually causes no symptoms and does not significantly limit heart function, interventions are rarely necessary. However, an intervention is useful, for example, if the opening area of ​​the pulmonary valve continues to increase.

pulmonary valve stenosis

Pulmonary valve stenosis can be treated with medication. In advanced pulmonary valve stenosis, repair or replacement may be performed. Interventional and operative procedures are also available for this kind of heart valve defect. The flap can be expanded or replaced as with other valve narrowings.

Tricuspid valve insufficiency and tricuspid valve stenosis

These rare heart valve defects are treated as soon as they affect cardiovascular function. Their symptoms are usually mild. Do not help medication, so first a repair of the flap can be tried. In the case of tricuspid valve insufficiency, for example, the introduction of a ring into the valve area (ring annuloplasty) is suitable. In addition, the possibility of a valve replacement remains.

Heart transplantationHeart defect: disease course and prognosis

Heart valve defects can not only limit the quality of life but also the lifetime as the entire cardiovascular system suffers. Die Prognose bei Herzklappenfehlern hängt in erster Linie davon ab, welche Herzklappe betroffen ist und ob der Herzklappenfehler bereits die Herzfunktion beeinflusst hat. Wird ein großer Herzklappenfehler nicht behandelt, führt er im Lauf der Zeit zu einer Herzschwäche und zu einer schlechten Prognose.

Leichte Herzklappenfehler müssen zwar häufig zunächst nicht operiert, aber dennoch behandelt werden. Wurden Herzklappenfehler diagnostiziert und werden behandelt, ist die regelmäßige (mindestens jährliche) Überwachung durch einen Kardiologen wichtig, um die den Behandlungserfolg zu überprüfen und damit auch die Prognose zu verbessern.