Mount Auburn Healthcare Connection

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“Today, roughly 60 percent of cardiac surgeries are for coronary artery disease, while 40 percent are for valvular heart disease,” says Vladimir Birjiniuk, M.D., Chief, Cardiac Surgery at Mount Auburn Hospital in Cambridge, a teaching hospital of Harvard Medical School. Valvular heart disease is any dysfunction or abnormality that occurs in one or more of the heart valves.

“Valvular heart disease is quite common and, unlike coronary heart disease, can even develop in people who are in the best shape of their lives,” says Dr. Birjiniuk. “Although valvular heart disease of the mitral valve can result from coronary artery disease, the majority of people with valvular heart disease have a genetic predisposition for it, and depending on the individual, the effects can occur at any age.”

The heart has four valves: pulmonary, aorta, tricuspid and mitral. “Valvular heart disease can affect one or more of these valves,” explains Dr. Birjiniuk. “However, the pulmonary valve is affected the least, except in some congenital forms.”

Valvular disease of the aortic valve
A common condition of the aortic valve is called bicuspid aortic valve. “A healthy aortic heart valve has three leaflets that extend from the aorta, but someone with a bicuspid aortic valve only has two leaflets,” says Dr. Birjiniuk. “People with this form of valvular disease are born with it. Some people with this condition can develop calcifications later in life, typically in their 60s, while others can go their entire lives without symptoms.”

This calcification, or calcium sediment in the valve, may cause aortic stenosis, which means narrowing of the valve. As a result, blood is unable to adequately flow from the heart to the body. Patients with this condition may have shortness of breath, chest pain, tendency to faint or all of these symptoms. The most common cause of aortic stenosis in the adult population is degenerative aortic stenosis, which is calcification in regular tricuspid aortic valves.

Aortic stenosis itself may also cause aortic regurgitation or insufficiency, which means that the valve does not close adequately because of the calcium deposit, and blood, rather than flowing forward to the body, flows backwards into the heart.

Aortic regurgitation tends to cause shortness of breath and congestive heart failure. It can be caused by numerous conditions such as bicuspid aortic valve (which was mentioned earlier), connective tissue disorders, infections of the valve, dilation of the structures supporting the valve mechanism, trauma and rheumatic valve disease.

Valvular disease of the mitral valve
Mitral stenosis occurs when the heart’s mitral valve fails to open completely. However, with the decline of rheumatic heart disease, mitral stenosis is less common. Other conditions leading to mitral stenosis are severe calcifications of the leaflets, some congenital defects, infection of the valve and metabolic disorder. Some drugs can also cause mitral stenosis. The most common symptom is shortness of breath, often followed by irregular heartbeats.

Mitral regurgitation, a condition when the mitral valve fails to close completely, can also result from rheumatic heart disease. However, the most common cause of mitral regurgitation is Myxomatous Degeneration of the mitral valve, also known as floppy mitral valve or mitral valve prolapse. This is a congenital defect of the connective tissue, which affects the valve leaflets and the support mechanism of the valve.

Another major cause of mitral regurgitation is functional, which means that the structure of the valve is normal, and the valve is failing to close because of the heart’s function. Factors leading to this condition are reduced blood supply to the heart and heart attack. Cardiomyopathies, a primary disease of the heart muscle, can also lead to mitral regurgitation.

“These conditions can cause a vicious cycle. When the mitral valve isn’t closing properly, the heart muscle weakens, causing the mitral valve to become even more dysfunctional and so on,” says Dr. Birjiniuk. “Most patients are diagnosed with mitral valve disease because they are being seen for heart palpitations. Fatigue and shortness of breath are also common symptoms with this condition.”

Valvular disease of the tricuspid valve
“The tricuspid valve rarely has a primary disease occurring in it,” says Dr. Birjiniuk. “More often, this valve is affected as a secondary disease from the mitral valve, which causes pressure to build in the lungs and the tricuspid valve to fail.” Pulmonary valve disease and primary pulmonary hypertension, or pressure in the lungs, are other causes for disease in the tricuspid valve. Swelling in the feet is the most common symptom.

Treatment of valvular disease
Most valvular diseases are initially treated with medication therapy. However, eventually surgery may be needed. Surgery should be performed relatively soon in any valvular heart disease. In the past, patients were referred to surgery only as a last resort. However, today, evidence shows that early referral is highly beneficial in reducing the risk of death and complications. Surgery also delivers superior long-term results, increasing patients’ quality of life and longevity. “In most cases, the aortic valve will need to be replaced. However, some patients may only need a repair,” says Dr. Birjiniuk. “Most mitral, tricuspid and pulmonary valves can be repaired, but sometimes they need to be replaced.”

If a replacement is needed, there are two main kinds of valves: biological and mechanical. “Biological valves last for about 15 years and patients don’t have to take blood thinners,” says Dr. Birjiniuk. “Mechanical valves last a lifetime, but blood thinners are necessary.” Determining what kind of valve a patient receives is highly individualized and can depend on a variety of factors.

At Mount Auburn Hospital, doctors are adopting the latest advancements to provide patients with the best possible outcomes. “There is a lot of research being done on better products and ways to preserve and fixate valves,” says Dr. Birjiniuk. “And at Mount Auburn Hospital, we have a very personal patient approach with exceptional surgical results.”