Treatments for heart valve disease

Aortic valve stenosis is the most common type of heart valve disease in Germany and similar countries. It occurs when the valve between the lower left heart chamber (left ventricle) and the aorta (main artery) becomes too narrow. As a result, the heart has to work harder to pump enough blood around your body. If that causes problems or if there is a risk of complications, the narrowed valve is usually replaced with an artificial (prosthetic) heart valve. This may have to be done through open heart surgery, but artificial heart valves can often be implanted using a catheter instead. There are two types of artificial heart valves:

• Mechanical prosthetic valves: Various types of prosthetic valves can take on the function of the natural heart valve. These artificial valves are made out of metal or a synthetic material. If they close properly, you can hear a quiet clicking sound every time the heart beats. The advantage of mechanical valves is that they last a long time. For this reason, they are mainly used in younger people – but they generally aren’t used much nowadays. The disadvantage of mechanical valves is that blood clots may form on them and block the whole valve (prosthetic valve thrombosis). Blood clots might also break free and travel around the body in the bloodstream, where they may block a blood vessel (embolism). If that happens in the brain, it leads to a stroke. In order to prevent these kinds of complications, people who have a mechanical prosthetic heart valve take blood-thinning (anticoagulant) medication for the rest of their life. This medication can lead to side effects such as bruising. Severe bleeding in the gastrointestinal (digestive) tract or brain are rare but potentially life-threatening side effects.
• Bioprosthetic (tissue) valves: This kind of replacement valve is made out of biological tissue such as the heart tissue of cows or pigs. Sometimes, but only very rarely, the donated heart valves of people who have passed away are used. People who have a bioprosthetic valve don’t necessarily have to take anticoagulants to reduce blood clotting. But these valves don’t last as long as mechanical valves do: For instance, there is an increased risk of bioprosthetic aortic valves becoming stiff and thicker after 10 to 15 years, and further surgery may then be needed. Bioprosthetic heart valves are generally used in people over the age of 60 or in younger people who can’t take blood-thinning medication over the long term.

In some young people the aortic valve can be replaced with a different heart valve of theirs. The heart valve between their right ventricle and their pulmonary artery (the pulmonary valve) is removed and used to replace the diseased aortic valve. The removed pulmonary valve is replaced with a bioprosthetic valve. Prosthetic heart valves last longer in that position because there is less strain on them there.

The second most common type of heart valve disease is known as mitral regurgitation or mitral insufficiency. It occurs when the valve between the left atrium (upper heart chamber) and the left ventricle (lower heart chamber) doesn’t close tightly. This means that when the left ventricle contracts (squeezes), some of the blood flows back into the left ventricle rather than into the body.

Like aortic valve stenosis, mitral valve regurgitation can be treated with a prosthetic heart valve. But faulty mitral valves are usually repaired rather than replaced. This is done using a catheter procedure or through open heart surgery.

Doctors call this type of treatment “heart valve repair.” Depending on the problem, the heart valve can be repaired in different ways. For instance, it can be strengthened a little using tissue taken from the sac surrounding the heart (the pericardium). If the mitral valve is leaky because it is no longer properly attached to the heart muscle, it can be reconnected using a strong thread made from synthetic material. If the valve is too wide, it can be tightened by implanting an artificial ring, allowing the valve to close better again.

In a different procedure, a small metal clip is used to clip the flaps of the leaky valve together, helping the valve to shut properly again.

The above-mentioned treatment approaches can also be used to treat less common types of heart valve disease. If the aortic valve is leaky (aortic regurgitation), heart valve repair can help. But it usually makes more sense to replace the valve.

In catheter treatment, a thin tube ( catheter) is inserted into a blood vessel through a small cut – usually in the groin.  The catheter is pushed through the blood vessel into the heart. Devices and instruments such as a prosthetic aortic valve or a mitral valve clip can be guided into the heart through the catheter. Catheter procedures are less likely to result in complications like wound healing problems or infections. Instead, they tend to lead to side effects such as an irregular heartbeat (arrhythmia) or damage caused by the catheter. But people usually recover faster from catheter procedures than they do from open heart therapy. Research hasn't yet shown whether catheter treatment also has more advantages in the long term, though.

In open heart surgery, the rib cage is opened under general anesthesia. The heartbeat is stopped. During the operation, a heart-lung machine (cardiopulmonary bypass machine) pumps the blood around the body instead. This kind of operation puts a strain on your body and it takes some time for the wound to heal. The possible complications include bleeding and infections. Complications are more likely to occur in people who are old, frail or already weakened by a different health problem.

It is sometimes possible to do the surgery through a smaller incision (cut) instead, though. This is known as keyhole surgery or minimally invasive surgery. Keyhole surgery is generally only done if catheter treatment or open heart surgery aren't possible.

Although medication can’t fix heart valve problems, it is sometimes part of the treatment – for instance, the blood-thinning (anticoagulant) medication that is used after receiving a prosthetic heart valve. But medication can also help if heart valve disease has led to other health problems, such as heart failure. Blood-pressure-lowering medication or diuretics (“water pills”) can then be used.

If someone only has slightly diseased heart valves without any symptoms, they often don't need treatment. Instead, they usually have regular check-ups to see whether the function of the valve is getting worse or whether they have started noticing any symptoms. But very frail people who have severe heart valve disease may also decide not to have treatment if it wouldn’t help them live longer or improve their quality of life.