Heart Valve Disease, Murmurs and Valve Surgery

Heart valve disease means one of the heart's four valves is not working properly. A valve may be narrowed, so blood struggles to get through, which is called stenosis. Or it may leak, so blood flows backwards, which is regurgitation. Both make the heart work harder, and an echocardiogram finds both.

What is a heart murmur, and does it always mean valve disease?

A murmur is the sound of turbulent blood inside the heart, heard through a stethoscope. It is a clue rather than a diagnosis. Plenty of murmurs are innocent, and others appear temporarily with fever, anaemia or pregnancy. Only an ultrasound of the heart can say whether a valve is genuinely diseased.

Murmurs deserve investigation when they are new, when they are loud, or when they come with breathlessness, chest discomfort, fainting or reduced stamina. They matter too in anyone with a history of rheumatic fever, a known valve problem, or a heart that looked enlarged on a previous scan. A murmur found by chance in a healthy adult with no symptoms is still worth one echocardiogram, if only to settle the question properly.

What are the symptoms of heart valve disease?

Early valve disease usually causes nothing at all. As it progresses, the commonest symptoms are breathlessness on effort, tiredness, palpitations and swelling. Aortic narrowing in particular can cause dizziness, chest tightness or fainting during exertion, and that combination always needs urgent assessment.

Patients describe the symptoms like this:

• Breathlessness climbing stairs or walking uphill
• Getting tired far sooner than others of the same age
• A fluttering or irregular heartbeat
• Dizziness or blackouts during effort
• Chest heaviness on exertion
• Swollen feet or a tight abdomen
• A dry cough at night, or breathlessness lying flat

In severe mitral valve narrowing, patients sometimes cough up blood-streaked sputum. That symptom needs same-day medical assessment.

What causes heart valve disease, and why is rheumatic damage still common in Pakistan?

Valves are damaged in four main ways: rheumatic fever after a throat infection, age-related calcium build-up, a valve that was abnormal from birth, or infection of the valve itself. In our region the first of these is still a leading cause, and it strikes young.

The World Health Organization reports that rheumatic heart disease remains common in low- and middle-income countries, where it mainly affects children and young adults, and that it follows untreated or inadequately treated streptococcal throat infection. The chain is straightforward. A sore throat, then rheumatic fever weeks later, then valve scarring that gets worse with every repeat attack.

Other causes and risk factors include:

• Age-related calcification, which stiffens the aortic valve in older adults.
• A bicuspid aortic valve, a congenital variation present from birth that wears out earlier than a normal valve.
• Infective endocarditis, meaning infection settling on a valve, often after a dental or skin infection.
• Damage after a heart attack, when the muscle supporting a valve is weakened.
• An enlarged heart from heart failure or long-standing high blood pressure, which stretches a valve ring until it leaks.

Which valve problems are most common?

Four patterns account for most of the valve disease we see in clinic: mitral stenosis, mitral regurgitation, aortic stenosis and aortic regurgitation. Each affects a different valve in a different direction, and each tends to announce itself with a particular symptom. The table below sets out what happens and what patients usually notice first.

When should you go to the Emergency?

Call 1122 or go straight to DHQ Hospital Abbottabad Emergency if you faint or nearly faint, if you have chest pain, if you become severely breathless at rest or cannot lie flat, or if you cough up blood-streaked or pink frothy sputum.

Two situations specific to valve patients also need emergency assessment:

• Fever lasting several days in someone with known valve disease or an artificial valve, especially alongside night sweats, weight loss or new weakness. This may be infective endocarditis, and it must not be shrugged off as ordinary flu.
• Sudden weakness on one side, facial drooping or slurred speech, which suggests a stroke. That is a particular risk once valve disease has caused atrial fibrillation.

If you take warfarin for a valve and you have heavy bleeding, black stools, or a significant head injury, go to the Emergency too.

How is heart valve disease diagnosed?

Examination finds the murmur. An echocardiogram makes the diagnosis. The ultrasound shows which valve is affected, whether it is narrowed or leaking, how severe that is, and how the heart muscle is coping. Every treatment decision rests on those four facts.

The usual work-up includes:

• Echocardiography, the central test, repeated periodically to track change over time.
• An ECG, which may show an enlarged chamber or atrial fibrillation.
• A chest X-ray to assess heart size and lung congestion.
• Holter monitoring when palpitations or intermittent atrial fibrillation are suspected.
• An ETT (Exercise Tolerance Test) in selected patients, to check how symptoms and blood pressure respond to effort.
• Angiography before valve surgery in adults, to check whether the coronary arteries need attention at the same time.
• Blood cultures when infection of a valve is suspected.

Dr. Muhammad Ali Khan, Consultant Cardiologist, assesses murmurs and valve disease in Abbottabad and arranges echocardiography, so that mild disease is monitored sensibly and severe disease is referred for intervention at the right moment. European Society of Cardiology guidelines base the timing of valve intervention on severity, symptoms and heart function rather than on age alone.

How is heart valve disease treated?

Treatment depends entirely on severity. Mild disease is simply monitored. Moderate disease is monitored more closely, with medicines for symptoms. Severe disease is corrected mechanically, because no tablet can reopen a narrowed valve or reseal a leaking one, however good the prescription.

The options are:

• Watchful monitoring, with a repeat echocardiogram at planned intervals.
• Medicines for symptom relief: diuretics for fluid, rate control for atrial fibrillation, blood pressure treatment, and heart failure medicines where the muscle is affected.
• Secondary penicillin prophylaxis after rheumatic fever, to prevent the repeat attacks that would damage the valve further.
• Anticoagulation for atrial fibrillation and for mechanical valves, monitored with INR blood tests when warfarin is used.
• Balloon valvotomy, a catheter procedure that opens a suitable narrowed mitral valve without open surgery.
• Surgical repair, which preserves your own valve and is often preferred for a leaking mitral valve.
• Valve replacement with a mechanical or tissue valve when repair is not possible, with the choice guided by age, pregnancy plans and how practical INR monitoring will be.

The American Heart Association emphasises that valve intervention is best timed before the heart muscle is permanently weakened, which is exactly why regular follow-up echocardiograms matter even during the years you feel well.

How do you live with heart valve disease?

Most people with mild or moderate valve disease live normally, work and travel, provided they keep their follow-up appointments and protect the valve they have. The two habits that matter most are attending your scheduled echocardiograms and looking after your teeth and gums.

Day-to-day priorities:

• Keep every prophylaxis dose if you have had rheumatic fever. The schedule runs for years, not months.
• Brush and floss daily, and treat dental problems early. Tell every dentist about your valve.
• Take fever seriously. Unexplained fever lasting several days with a known valve problem needs medical review and blood tests before antibiotics are started at random.
• If you take warfarin, keep your INR appointments and keep your intake of green vegetables steady rather than swinging.
• Report new or worsening symptoms early, whether that is increasing breathlessness, new swelling, palpitations or any faint.
• Plan pregnancy in advance with your cardiologist if you have significant valve disease or a mechanical valve.
• Stay active within advice. Regular walking is usually encouraged, while competitive or very heavy exertion needs individual clearance, particularly with aortic narrowing.