Aortic valve disease

Aortic valve disease is a type of heart valve disease. In aortic valve disease, the valve between the lower left heart chamber (left ventricle) and the main artery to the body (aorta) doesn't work properly.

The aortic valve helps keep blood flowing in the correct direction through the heart. A damaged or diseased aortic valve can affect blood flow to the rest of the heart and body.

Aortic valve disease includes:

• Aortic valve stenosis. The flaps (cusps) of the aortic valve become thick and stiff, or they fuse together. These problems cause the valve opening to become narrow. The narrowed valve reduces or blocks blood flow from the heart to the rest of the body.
• Aortic valve regurgitation. The aortic valve doesn't close properly, causing blood to flow backward into the left lower heart chamber (ventricle).

Aortic valve disease may be present at birth (congenital heart disease), or it may occur later in life due to other health conditions.

Treatment for aortic valve disease depends on the type and severity of disease. Some people may need surgery to repair or replace the aortic valve.

Symptoms

Some people with aortic valve disease may not notice symptoms for many years. Signs and symptoms of aortic valve disease may include:

• Whooshing or swishing heart sound (heart murmur)
• Chest pain or tightness
• Dizziness
• Fainting
• Fatigue after activity or having less ability to be active
• Irregular heartbeat
• Shortness of breath, particularly during vigorous activity or when lying down
• Not eating enough (mainly in children with aortic valve stenosis)
• Not gaining enough weight (mainly in children with aortic valve stenosis)

When to see a doctor

If you're having sudden chest pain, get emergency medical help.

Make an appointment with a health care provider if you have signs or symptoms of valve disease, such as shortness of breath, fatigue after activity, or sensations of a pounding or an irregular heartbeat. Sometimes the first signs of aortic valve disease are related to heart failure. See a health care provider if you have fatigue that doesn't get better with rest, shortness of breath, and swollen ankles and feet, which are common symptoms of heart failure.

Causes

Aortic valve disease may be caused by a heart defect present at birth (congenital heart defect). Other causes of aortic valve disease later in life include:

• Age-related changes to the heart
• Infections
• High blood pressure
• Injury to the heart

To better understand the causes of aortic valve disease, it may be helpful to know how the heart valves typically work.

The heart has four valves that keep blood flowing in the correct direction. These valves are:

• Aortic valve
• Mitral valve
• Tricuspid valve
• Pulmonary valve

Each valve has flaps (cusps or leaflets) that open and close once during each heartbeat. Sometimes, a valve doesn't open or close properly. This can reduce or block blood flow through the heart to the rest of the body.

In aortic valve disease, the valve between the lower left heart chamber (left ventricle) and the body's main artery (aorta) doesn't work properly. The valve may be thickened and stiff (stenosis) or it may not close properly, causing blood to flow backward.

Risk factors

Many things can raise the risk of aortic valve disease, including:

• Older age. Calcium deposits can build up on the aortic valve as people age, causing the aortic valve to stiffen and become narrow.
• Heart valve problems present at birth (congenital heart defects). Some people are born with a missing, extra or fused valve flap (cusp), increasing the risk of aortic valve regurgitation.
• Rheumatic fever. This complication of strep throat can cause aortic stenosis, a type of valve disease. If you have heart valve disease due to rheumatic fever, it's called rheumatic heart disease. If not, it's called nonrheumatic heart disease.
• Inflammation of the lining of the heart's chambers and valves (endocarditis). This life-threatening condition is usually caused by infection. It can damage the aortic valve.
• History of radiation therapy to the chest. Some types of cancer are treated with radiation therapy. Symptoms of heart valve disease may not be noticed until many years after radiation therapy is received.
• Other health conditions. Chronic kidney disease, lupus and Marfan syndrome, a connective tissue disease, can increase the risk of aortic stenosis or regurgitation.

Complications

Potential complications of aortic valve disease may include:

• Blood clots
• Stroke
• Heart failure
• Heart rhythm problems (heart arrhythmias)
• Death due to sudden cardiac arrest

Proper diagnosis and treatment can help reduce the risk of complications.

Diagnosis

To diagnose aortic valve disease, a health care provider will usually do a physical exam and ask questions about your signs and symptoms and medical history.

A health care provider may hear a whooshing or swishing sound (heart murmur) when listening to your heart with a stethoscope. If so, you may be referred to a doctor trained in heart diseases (cardiologist).

Several tests may be done to diagnose aortic valve disease, including:

• Echocardiogram. An echocardiogram is an ultrasound of the heart. Sound waves are used to create pictures of the heart in motion. An echocardiogram provides a closer look at the condition of the aortic valve and the aorta. It can help determine the cause and severity of aortic valve disease.

  In a standard echocardiogram, a wandlike device (transducer) that gives off sound waves is gently pressed against the skin of the chest above the heart. Sometimes, a transesophageal echocardiogram may be done to get a closer look at the aortic valve. In this type of echocardiogram, a small transducer attached to the end of a tube is inserted down the tube leading from the mouth to the stomach (esophagus).

• Electrocardiogram (ECG or EKG). This noninvasive test records the electrical activity of the heart. Sticky patches with sensors (electrodes) are placed on the chest and sometimes the legs. Wires connect the patches to a computer, which displays results.
• Chest X-ray. A chest X-ray can show the condition of the heart and lungs. A health care provider may use the test result to see if the heart is enlarged, which can be a sign of certain types of aortic valve disease or heart failure. A chest X-ray may also show calcium buildup on the aortic valve or fluid in the lungs.
• Cardiac MRI. A cardiac MRI uses magnetic fields and radio waves to create detailed images of the heart. This test may be used to determine the severity of aortic valve disease and measure the size of the aorta.
• Cardiac computerized tomography (CT) scan. A cardiac CT scan uses a series of X-rays to create detailed images of the heart and heart valves. Doctors may use this imaging technique to measure the size of the aorta and look at the aortic valve more closely. A CT scan may be used to evaluate the size of the aorta, measure the amount of calcium in the aortic valve or determine the severity of aortic valve stenosis.
• Exercise tests or stress tests. These tests often involve walking on a treadmill or riding a stationary bike while an ECG or echocardiogram is done. Exercise tests help reveal how the heart responds to physical activity and whether valve disease symptoms occur during exercise. If you are unable to exercise, medications that have similar effects as exercise on your heart may be used.
• Cardiac catheterization. This test isn't often used to diagnose aortic valve disease. However, it may be used to determine the severity of aortic valve disease or to diagnose the condition if other tests can't. In this test, a thin, flexible tube (catheter) is inserted into a blood vessel, usually in the groin area or arm, and guided to the heart. Cardiac catheterization can give more details about blood flow and how well the heart is working. Certain heart treatments can be done during cardiac catheterization.

Staging

After testing confirms a diagnosis of aortic or other heart valve disease, your health care provider may tell you the stage of disease. Staging helps determine the most appropriate treatment.

The stage of heart valve disease depends on many things, including symptoms, disease severity, the structure of the valve or valves, and blood flow through the heart and lungs.

Heart valve disease is staged into four basic groups:

• Stage A: At risk. Risk factors for heart valve disease are present.
• Stage B: Progressive. Valve disease is mild or moderate. There are no heart valve symptoms.
• Stage C: Asymptomatic severe. There are no heart valve symptoms but the valve disease is severe.
• Stage D: Symptomatic severe. Heart valve disease is severe and is causing symptoms.

Treatment

Treatment for aortic valve disease depends on:

• The severity (stage) of aortic valve disease
• Whether the disease is causing symptoms
• Whether the condition is getting worse

Treatment may include monitoring, lifestyle changes, medications, or surgery or other procedures. If you have aortic valve disease, consider being evaluated and treated at a medical center with a multidisciplinary team of heart disease specialists (cardiologists) and others trained and experienced in evaluating and treating heart valve disease.

Medications

If aortic valve disease is mild or moderate or if you aren't having symptoms, you may only need regular medical checkups to monitor the condition.

Heart-healthy lifestyle changes and medications may be recommended to treat symptoms of aortic valve disease or reduce the risk of complications. For example, medications may be used to:

• Lower blood pressure
• Prevent irregular heartbeats
• Remove excess fluid from the body to reduce the strain on the heart

Surgery or other procedures

Eventually, surgery or a catheter procedure may be needed to repair or replace the diseased aortic valve. Some people with aortic valve disease need surgery even if it's not severe or when it's not causing symptoms.

Surgery to repair or replace an aortic valve is often done with open-heart surgery. Sometimes, the valve can be replaced during minimally invasive heart surgery, which uses smaller incisions than those needed for open-heart surgery, or with a catheter-based procedure.

Aortic valve repair

During aortic valve repair, the surgeon may do one or all of the following:

• Separate valve flaps (cusps) that have fused
• Add support to the base of the valve
• Reshape or remove excess valve tissue so that the cusps can close tightly
• Patch holes or tears in a valve

Aortic valve repair often requires open-heart surgery. However, less invasive options may be available. For example, a catheter procedure may be used to insert a plug or device to repair a leaking replacement aortic valve.

In infants and children with aortic valve stenosis, a less invasive procedure called balloon valvuloplasty may be done to temporarily open a narrowed valve. During this procedure, the doctor inserts a thin, hollow tube (catheter) into a blood vessel, usually in the groin, and threads it to the heart. A balloon is inflated to widen the valve opening, and then deflated and removed. This valve repair procedure may also be done in adults who are too sick for surgery or who are waiting for a valve replacement.

Aortic valve replacement

In aortic valve replacement, a surgeon removes the damaged valve and replaces it with a mechanical valve or a valve made from cow, pig or human heart tissue (biological tissue valve).

Sometimes, the aortic valve is replaced with your own lung (pulmonary) valve. Then your pulmonary valve is replaced with a biological lung tissue valve. This more complicated surgery is called the Ross procedure.

You and your health care provider will discuss the benefits and risks of each type of valve to choose the best option for you.

Aortic valve replacement typically requires open-heart surgery, which involves a cut (incision) in the chest. Sometimes, surgeons can use a minimally invasive procedure called transcatheter aortic valve replacement (TAVR) to replace a narrowed aortic valve with a biological tissue valve. TAVR uses smaller incisions than those used in open-heart surgery. TAVR may be an option for people at increased risk of heart valve surgery complications.

Lifestyle and home remedies

After diagnosis or treatment of aortic valve disease, you'll need regular health checkups to monitor your condition. Your health care provider may suggest making heart-healthy lifestyle changes, including:

• Eating a heart-healthy diet. Eat a variety of fruits and vegetables, low-fat or fat-free dairy products, poultry, fish, and whole grains. Avoid saturated and trans fats and excess salt and sugar.
• Maintaining a healthy weight. Ask your health care provider what a healthy weight is for you. If you're overweight or obese, your health care provider may recommend that you lose weight.
• Getting regular exercise. As a general goal, aim for at least 30 minutes of moderate physical activity every day. Ask your health care provider before starting a new exercise routine.
• Managing stress. Find ways to help reduce emotional stress. Getting more exercise, practicing mindfulness and connecting with others in support groups are some ways to tame stress.
• Quitting smoking. If you need help quitting smoking or using tobacco, ask your health care provider about resources to help. Joining a support group may be helpful.

For women with aortic valve disease, it's important to talk with a health care provider before becoming pregnant. Your health care provider can discuss with you which medications you can safely take and whether you may need a procedure to treat your valve condition prior to pregnancy.

Women with aortic valve disease likely require close monitoring by a health care provider during pregnancy. Health care providers may recommend that women with severe heart valve disease avoid pregnancy to avoid the risk of complications.

Coping and support

If you have aortic valve disease, here are some steps that may help you manage the condition:

• Take medications as prescribed. Take your medications as directed by your health care provider.
• Get support. Connecting with others who have the same or a similar condition may be helpful. Ask your health care provider about support groups in your area.
• Stay active. Regular exercise is one of the best ways to improve heart health. Ask your health care provider about how much and what types of physical activity are safe for you.

Preparing for an appointment

If you think you have aortic valve disease, make an appointment to see your health care provider. Here's some information to help you prepare for your appointment.

• Be aware of pre-appointment restrictions. When you make the appointment, ask if there's anything you need to do beforehand.
• Write down your symptoms, including any that seem unrelated to heart valve disease.
• Write down key personal information, including a family history of heart disease, and any major stresses or recent life changes.
• Make a list of all medications, vitamins and supplements you take.
• Take a family member or friend along, if possible. Someone who accompanies you can help you remember information you receive.
• Be prepared to discuss your diet and exercise habits. If you don't already eat well and exercise, be ready to talk to your health care provider about challenges you might face in getting started.
• Write down questions to ask your health care provider.

For aortic valve disease, some basic questions to ask your health care provider include:

• What is likely causing my symptoms or condition?
• What are other possible causes for my symptoms or condition?
• What tests will I need?
• What's the best treatment?
• What are the alternatives to the primary approach you're suggesting?
• I have other health conditions. How can I best manage them together?
• Are there restrictions I need to follow?
• Should I see a specialist?
• If I need surgery, which surgeon do you recommend for heart valve surgery?
• Is there a generic alternative to the medicine you're prescribing?
• Are there brochures or other printed material I can take with me? What websites do you recommend?

Don't hesitate to ask other questions you have.

What to expect from your doctor

Your health care provider is likely to ask you a number of questions, including:

• When did your symptoms begin?
• Have your symptoms been continuous or occasional?
• How severe are your symptoms?
• What, if anything, seems to improve your symptoms?
• What, if anything, appears to worsen your symptoms?

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