Valvular Heart Disease
Valvular heart disease describes any condition affecting one or more of the heart’s four valves—the mitral, aortic, tricuspid, and pulmonary valves. These valves keep blood flowing in the correct direction through the heart, and when they fail to open fully (stenosis) or close completely (regurgitation), the heart must work harder, eventually leading to symptoms or structural changes. Causes range from age-related degeneration and prior rheumatic fever to congenital abnormalities, infections, and other heart conditions. Echocardiography is the primary tool for diagnosis, with cardiac MRI, CT, and catheter-based studies adding important information.
What is it?
The heart has four valves that control the flow of blood through its four chambers. The mitral valve sits between the left atrium and left ventricle; the aortic valve sits between the left ventricle and the aorta; the tricuspid valve sits between the right atrium and right ventricle; and the pulmonary valve sits between the right ventricle and the pulmonary artery. Each valve opens to allow blood to flow forward and closes to prevent it from flowing backward. Valvular heart disease describes any condition in which one or more of these valves do not work normally.
Valvular problems generally fall into two main categories. Stenosis is a narrowing of the valve that prevents it from opening fully, forcing the heart to work harder to push blood through. Regurgitation (also called insufficiency) is a leak in which the valve does not close completely, allowing blood to flow backward and increasing the volume of blood the heart must handle. Some valves develop both stenosis and regurgitation at the same time. Each of the four valves can be affected; the mitral and aortic valves are most commonly involved in adults.
There are many possible causes. Age-related degeneration is one of the most common causes of valve disease in older adults, particularly producing calcific aortic stenosis and degenerative mitral valve disease. Congenital valve abnormalities, such as bicuspid aortic valve (in which the valve has two leaflets instead of three), are common and predispose to dilation of the aorta and to valve disease later in life. Rheumatic heart disease—caused by an immune response after streptococcal infection—remains an important cause of valve disease in many parts of the world. Other contributors include endocarditis (infection of a valve), prior heart attack with damage to the structures supporting the mitral valve, dilation of the heart chambers and great vessels, certain medications, radiation, and rare connective tissue or systemic conditions.
Symptoms depend on which valve is affected and how severely. Many people with mild valve disease have no symptoms and may only have a heart murmur identified during a physical examination. As valve disease becomes more significant, symptoms may include shortness of breath (especially with exertion or when lying flat), fatigue, reduced exercise tolerance, chest discomfort, palpitations, lightheadedness, fainting, leg swelling, or signs of heart failure. Some valve diseases—particularly severe aortic stenosis—may first present with sudden symptoms such as fainting or, less commonly, cardiac arrest. Other types of valve disease, such as severe regurgitation, often develop more gradually.
Evaluation begins with a careful history and physical examination, including listening for heart murmurs and other findings. ECG provides information about heart rhythm and chamber strain. Echocardiography is the central imaging test for valve disease; transthoracic echocardiography is widely available and provides detailed information about valve structure and function, chamber sizes, pumping function, and pressures. Transesophageal echocardiography offers higher-resolution images and is particularly useful for detailed assessment of valves (especially the mitral valve), evaluation for endocarditis, and procedural planning. Cardiac MRI provides additional information about chamber sizes, function, blood flow, and tissue characteristics. Cardiac CT is increasingly used for detailed valve and aortic anatomy and is central to planning transcatheter procedures. Stress testing may help clarify symptom significance, particularly when symptoms and resting findings are not aligned. Cardiac catheterization may be used to assess pressures, coronary anatomy, and severity of valve disease, particularly before procedures.
Important to Know
Management of valvular heart disease is highly individualized and depends on the specific valve involved, the type and severity of disease, the patient’s symptoms, the impact on heart function, and overall health. Many patients with mild or moderate valve disease can be managed safely with periodic monitoring and treatment of risk factors. Significant or symptomatic valve disease often requires definitive treatment with valve repair or replacement.
For mild and moderate valve disease, ongoing monitoring with echocardiography is typical, with the frequency tailored to the type and severity of disease. Treatment focuses on managing associated conditions, particularly blood pressure, heart failure, and arrhythmias (especially atrial fibrillation, which is common in valve disease). Anticoagulation may be needed for patients with atrial fibrillation, mechanical prosthetic valves, or certain other conditions.
Significant aortic stenosis is treated with valve replacement when patients become symptomatic or develop other high-risk features. Options include surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR); the choice depends on age, anatomy, surgical risk, and patient preferences. Severe mitral regurgitation may be managed with surgical repair (often preferred when feasible) or replacement, with transcatheter mitral valve interventions increasingly available for selected patients. Similar principles apply to the tricuspid and pulmonary valves, with both surgical and transcatheter options expanding in recent years.
Endocarditis is a serious infection of a heart valve that often requires prolonged intravenous antibiotics and, in many cases, surgical treatment. Prevention with appropriate dental and procedural antibiotics may be recommended in select high-risk patients.
Care is typically coordinated by primary care clinicians, cardiologists, and—when intervention is needed—cardiothoracic surgeons, interventional or structural cardiologists, and dedicated heart valve teams. Imaging findings are interpreted alongside symptoms, examination, and other test results.
Lifestyle measures—not smoking, healthy diet, regular physical activity (individualized when significant valve disease is present), weight management, treatment of sleep apnea, and good control of blood pressure, cholesterol, and diabetes—support overall cardiovascular health and may slow progression in some forms of valve disease.
Red flag symptoms include severe or worsening shortness of breath, chest pain, fainting (especially with exertion), severe palpitations or rapid heart rate with lightheadedness, severe leg swelling, signs of stroke, persistent fever (which may suggest endocarditis), or signs of shock. These warrant prompt or urgent medical evaluation.