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         Problems in heart valve

What is valvular heart disease?
Your heart is a muscle which pumps blood around your lungs and the rest of your body. There are four valves in your heart. These valves guard the entrances and exits of the two pumping chambers in your heart (the right and left ventricles). The job of a valve is to make sure that fluid flows only in the correct direction. The valves at the entrances to the pumping chambers are there to make sure that the blood only goes in. The valves at the exits only let blood out. A diseased or damaged valve can affect the flow of blood in two ways.

• If the valve does not open fully, it will obstruct the flow of blood. This is called valve stenosis.
• If the valve does not close properly, it will allow blood to leak backwards. This is called valve
incompetence or regurgitation.

Both stenosis and incompetence put an extra strain on the heart. If you have stenosis, the valve will obstruct the flow of blood, so your heart will have to pump harder to force the blood past the obstruction. If you have incompetence, your heart has to do extra work to pump the necessary volume of blood forwards against the blood flowing backwards through the leaking valve. As well as your heart having to work harder, the blood behind the affected valve will be under increased pressure, called ‘back pressure’. This can cause a build-up of fluid either in your lungs or in the lower part of your body, depending on the valve affected.

What are the symptoms of valvular heart disease?
The symptoms of valvular heart disease vary depending on which valve is affected. People with mild valvular heart disease may have few symptoms. However, increasing strain on the heart can cause tiredness or breathlessness when exercising, or palpitation. The back pressure can also cause shortness of breath, and swelling of the ankles and legs. A person with valvular heart disease may also get chest pains (angina) because there is not enough blood flowing through the coronary arteries. If the obstruction is severe, the person may have spells of dizziness and fainting.

How is valvular heart disease diagnosed?
Abnormalities of the heart valves are often picked up at a routine examination when the doctor listens to the heart with a stethoscope and hears an extra noise called a ‘murmur’. However, murmurs are also heard in completely normal hearts. The doctor will usually be able to tell from the type of murmur he or she hears whether you need to have further investigations. Even after a valve condition has been diagnosed, it can sometimes be 10 or even 20 years before you have any symptoms.

If you have symptoms that may be caused by a faulty valve, or if you have a murmur that is
suspicious, your doctor will probably arrange for you to have the following tests:

• an electrocardiogram (an ECG),which records the rhythm and electrical activity of your heart
• a chest X-ray, and
• an echocardiogram, which produces an ultrasound picture of the heart and valves.

There is also another test called ‘cardiac catheterisation’. This is not very often needed to
diagnose valvular heart disease, but you may need to have the test to assess how severe the disease is. This test can also tell whether there is any narrowing of your coronary arteries.

Cardiac catheterisation involves passing a catheter (a fine tube) through an artery in the groin, to the heart. A dye is then injected and X-rays are taken from several angles. This test is usually done as a day case,which means that you do not have to stay overnight in hospital. You will be given a local anaesthetic in the groin where they insert the catheter, so you should not feel any discomfort.

The cardiac catheterisation test can give vital information about the blood pressure in your heart and about how well the pumping chambers and valves are working.

What causes valvular heart disease?
The main causes of valvular heart disease are:
• being born with an abnormal valve or valves (congenital heart disease)
• the effects of rheumatic fever
• ageing of the heart
• cardiomyopathy, or
• ischaemic heart disease.
• congenital heart disease
Some people are born with an abnormal valve or valves. Fortunately,most of these people never experience any symptoms. However, in some people the condition can get worse over the years, causing stenosis or incompetence, or both. An abnormal valve is at a greater risk of becoming infected. This infection can also spread to the lining of the heart. The infection is known as endocarditis.

Rheumatic fever
The most common cause of serious valvular heart disease today is the long-term effect of rheumatic fever that occurred 20 to 30 years before. Rheumatic fever can affect one, two or three valves, causing stenosis or incompetence, or both. The most commonly affected valves are the aortic and mitral valves.

Ageing of the heart
Among older people the most common cause of valve disease is when a valve thickens and
becomes less supple and restricts the flow of blood. Investigation is needed to find out whether treatment is necessary, although in many cases it is not.

A disease of the heart muscle called cardiomyopathy can cause the muscle around the valve to thicken,which can obstruct the flow of blood.

Ischaemic heart disease
This happens when the heart muscle does not get a good supply of blood. This can make the heart muscle pump less efficiently and cause the valve to leak.

Treatment for valvular heart disease
Many people with valvular heart disease may need little treatment but may benefit from having a regular check-up, including an echocardiogram.

Some people may need to take drugs to relieve their symptoms. These drugs may include diuretics, ACE inhibitors and digoxin.

  • Diuretics, which encourage the body to produce urine, can relieve the build-up of fluid in the lungs and the lower part of your body.
  • ACE inhibitors reduce the amount of work the heart has to do, and improve the flow of blood to the heart muscle.
  • Digoxin stabilises the heart rhythm and helps the heart’s pumping action.

For further information about treatment, please refer to valve surgery section on this website.

Guarding against infection
Any abnormal valve is at greater risk of becoming infected. This is because any bacteria that is being carried in the blood can stick onto the uneven surface of the abnormal valve and stay there. The bacteria then grows and the infection can spread to the lining of the heart. This is known as endocarditis. It can happen even when the abnormality is mild and is not otherwise causing any trouble.

Endocarditis can be very serious and life-threatening. If treatment is not started quickly, it can affect the performance of the valve and the heart. Treatment involves having intravenous antibiotics (antibiotics injected directly into a vein) for quite a long time,which means a long stay in hospital. In some cases, it may be necessary to operate on the infected valve.

The most common source of bacteria is the mouth. The bacteria can enter the bloodstream through unhealthy gums, or when you have dental surgery. Fortunately, there are things you can do to prevent infection. The most important thing is to make sure that you keep your teeth and gums as healthy as possible. Make sure you go to your dentist for regular check-ups. If you need dental treatment, you should have a dose of antibiotics first. So, when your dentist is planning any dental treatment for you, discuss with him or her whether you will need to take antibiotics first. Women who are having an IUCD fitted for contraception should also take antibiotics first. You may need to take antibiotics before other surgical procedures too. For more details, talk to your doctor.

Valvular heart disease and pregnancy
Most women with mild to moderate valvular heart disease do not have heart trouble during pregnancy, although very careful medical supervision is always advisable. However, if the valve disease is severe, the risk of pregnancy to both mother and baby is greater.

If you have severe valvular heart disease and are keen to have a baby, your cardiologist may advise you to have valve surgery before you become pregnant. Occasionally, severe valve disease only comes to light during pregnancy. If this happens, it is usually possible to continue with the pregnancy under strict medical supervision. If necessary, you can have valve surgery while you are pregnant.

 Mitral valve prolapse
The mitral valve may be slightly deformed in about 5 in every 100 people, causing it to leak. This causes a heart murmur but only very rarely leads to problems. However, it is a possible site for infection and, if you have this condition, it is important to take antibiotics before dental treatment and surgery.

A murmur doesn’t mean that you definitely have valvular heart disease but if your doctor discovers that you have a murmur, you should have it investigated.

Yearly check-up
Most patients with valvular heart disease will have a yearly check-up with a cardiologist. This check-up is very important, even if you feel completely well.

The aim is to start medicine or to have surgery at the right time – before it is too late and there is permanent damage to the heart. The check-up usually includes an electrocardiogram (ECG), chest X-ray and echocardiogram. In many cases treatment will not be needed for many years, if ever, but a careful, regular watch will make sure that you get any treatment you need.
      Doctor Tips
Angina is an uncomfortable feeling or pain in the chest.
It usually feels like a heaviness or tightness.
      For healthcare professional
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