29 March, 2024

Heart Valves: Too Tight or Too Leaky

What is a valve?
A valve is a “device for controlling the passage of fluid or air through a pipe, duct, etc.” We all have encountered valves in our lives. A tire (or Tyre) valve is one example which allows air to be injected into the tire and doesn’t allow air to escape unless it is tampered with or is leaky. Essentially, valves are meant to allow one-way flow only.

Our heart also has valves to control blood flow from one chamber to the other.

A normal human being has four heart valves. They are named Tricuspid, Pulmonic, Aortic, and Mitral. A normal valve should allow blood to flow from chamber A to chamber B without restriction and prevent blood from flowing back into chamber A when the heart contracts. Due to various causes, valves can either become too tight, restricting blood flow from chamber A to B (a condition called ‘stenosis’) or don’t seal off too well when closed, leading to blood leaking from chamber B to A (a condition called ‘regurgitation’). So, for example, if the Aortic valve becomes too tight, it’s called ‘Aortic Stenosis’, or if it leaks, the condition is called ‘Aortic Regurgitation’.

Valve abnormalities (stenosis or regurgitation) cause abnormal flow dynamics inside the heart, leading to undue stress on the heart muscle. When such a condition becomes severe, it manifests as breathing difficulty, chest discomfort, dizziness, fainting, leg swelling, etc. Severe stenosis or regurgitation, particularly involving Aortic or Mitral valves, needs urgent medical attention.

Since valve abnormalities are mechanical, they need to be fixed mechanically. Medications may improve the patient’s symptoms but do nothing for valve disease per se. This generally holds true, although some exceptions do exist. So, it is important to seek expert opinion in such situations. Let me briefly touch upon a few of the valve scenarios:

Mitral Stenosis: This is a condition when the Mitral valve doesn’t open properly. When the problem worsens, the valve can be opened with Percutaneous Balloon Mitral Valvotomy (PBMV). Here, a balloon is threaded through the patient’s groin, placed at the Mitral valve orifice and inflated. An animation of this procedure can be watched online. PBMV is done in the cardiac cath lab, and the procedural setup is similar to an angioplasty. An alternative to PBMV is open heart surgery with mitral valve replacement.

Mitral Regurgitation: Here, the valve leaks, allowing blood to backflow. If severe, the valve is typically repaired or replaced via open heart surgery. A minimally invasive catheter-based procedure called Transcatheter edge-to-edge repair (TEER) is available for those patients for whom open heart surgery is considered high risk. Commercially available TEER devices are called Mitra-Clip or Pascal.

Aortic Stenosis: It is a condition where the Aortic valve is too tight, impeding blood flow from the heart to the rest of the body. Traditionally, all aortic stenosis was treated with valve replacement via open-heart surgery. A newer minimally-invasive procedure called Transcatheter Aortic Valve Replacement (TAVR or TAVI) can be offered to patients for whom open heart surgery is not desired. TAVR involves implanting a new valve in place of the diseased valve through a small cut in the groin. The procedure is very similar to angioplasty with speedy recovery. TAVR details are highlighted in this article.

Aortic Regurgitation: In this condition, the aortic valve is leaky, leading to blood backflow. Aortic regurgitation is primarily treated with valve replacement via open heart surgery. TAVR can be considered in cases where open heart surgery is not an option.

Tricuspid Regurgitation: A leaky tricuspid valve is mostly managed with medicines alone. If a patient is undergoing open heart surgery for aortic or mitral valve disorders, the surgeon will usually repair a leaking tricuspid valve as well. Dedicated surgery for tricuspid regurgitation is rarely performed due to the high surgical risk. Minimally invasive transcatheter valve implantation for tricuspid regurgitation is also available for patients with no relief from medications.

Tricuspid stenosis, Pulmonic stenosis, and Pulmonic regurgitation are other valvular abnormalities which are rather rare.

*Minimally-invasive transcatheter valve implantation is also available for those patients who previously had heart valve surgery and now have a recurrence of stenosis or regurgitation.

Patients with valve abnormalities who are otherwise feeling well should be constantly followed up with a cardiologist. The aim of such follow-up is to identify any potential problem before it permanently damages the heart and treat it. Patients with valve abnormalities who don’t feel well should seek immediate medical attention.

I am sure I didn’t answer all your questions on this topic. Feel free to message me with your queries; I will happily answer them.

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