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Valve DisordersEdit

Valve disorders encompass a spectrum of conditions that affect the heart’s four valves: the aortic, mitral, tricuspid, and pulmonary valves. These valves regulate unidirectional blood flow through the chambers of the heart, and when their structure or function is compromised, the heart must work harder to maintain circulation. Disorders can be congenital or acquired over a lifetime, and they range from mild, asymptomatic states to severe disease that requires urgent intervention. In recent decades, advances in diagnosis and treatment—especially in valve repair and transcatheter therapies—have transformed outcomes for many patients, while ongoing debates about access, cost, and long-term durability shape how care is delivered in different health systems. For context and further reading, see Aortic valve and Mitral valve.

Anatomy and physiology

The heart’s valves sit at the interfaces between the chambers and major vessels. The aortic valve sits between the left ventricle and the aorta, the mitral valve between the left atrium and left ventricle, the tricuspid valve between the right atrium and right ventricle, and the pulmonary valve between the right ventricle and the pulmonary artery. Proper valve function depends on a leaflet apparatus, a supportive ring (annulus), the surrounding chordae tendineae, papillary muscles, and the hemodynamic forces of the cardiac cycle. When a valve fails to open fully, it creates a stenotic lesion; when it fails to close fully, it allows regurgitation. Some diseases cause both obstruction and leakage at different stages of progression, and many patients have concomitant valve disease affecting more than one valve.

Common etiologies include degenerative calcification (especially in the aortic valve with aging or bicuspid anatomy), inflammatory or autoimmune processes (such as rheumatic disease historically, now less common in high-income countries for primary valve disease but still a major issue in others), infectious causes (infective endocarditis), and functional or secondary disease due to ventricular dilation or atrial arrhythmias. Congenital abnormalities, such as abnormal valve leaflet morphology, can predispose to early valve degeneration or prolapse. See Aortic stenosis and Mitral valve prolapse for prominent examples.

Common valve disorders

Aortic valve disorders are among the most frequent and consequential errors in valve function.

  • Aortic stenosis: This is a narrowing of the aortic valve opening, most commonly due to age-related calcification or bicuspid aortic valve anatomy. Symptoms include exertional chest pain, fainting (syncope), shortness of breath, and reduced exercise capacity. Diagnostic hallmarks include a characteristic systolic murmur and imaging showing restricted valve opening. Definitive treatment is valve replacement, today increasingly via transcatheter approaches. See Aortic valve and Aortic stenosis.

  • Aortic regurgitation (aortic insufficiency): Inadequate closure of the aortic valve leads to backflow into the left ventricle, producing a bounding pulse and heart failure symptoms if chronic. Management depends on severity and rate of progression, with repair or replacement indicated when significant, particularly if the ventricle dilates or function declines. See Aortic valve and Aortic regurgitation.

Mitral valve disease is another major category.

  • Mitral stenosis: Narrowing of the mitral orifice, classically caused by rheumatic disease, though degenerative changes can occur. This limits left atrial emptying into the left ventricle and can cause atrial enlargement and pulmonary congestion. Treatments include percutaneous balloon valvotomy or surgical repair/replacement. See Mitral valve and Mitral stenosis.

  • Mitral regurgitation (mitral insufficiency): Leakage of blood backward from the left ventricle into the left atrium during systole. Primary MR arises from leaflet or chordal pathology; secondary MR results from left ventricular dilation or ischemia affecting the subvalvular apparatus. Valve repair is preferred when feasible; replacement is considered if repair is unlikely to be durable. See Mitral valve and Mitral regurgitation.

  • Mitral valve prolapse: A common degenerative valve abnormality in which one or more leaflets bow into the left atrium during systole. Many individuals are asymptomatic, but some experience palpitations, chest pain, or arrhythmias. See Mitral valve prolapse.

Tricuspid and pulmonary valve diseases are less common but clinically important, particularly when they co-occur with disease of the left heart or arise from rheumatic disease, endocarditis, or dilation of the right heart.

  • Tricuspid regurgitation/disease: Regurgitation of the tricuspid valve often reflects right heart dilation and failure, though primary disease of the valve can occur. Management ranges from medical therapy to repair or replacement of the valve, and increasingly, transcatheter repair techniques are available in selected cases. See Tricuspid valve and Tricuspid regurgitation.

  • Pulmonary valve disease: Stenosis or regurgitation of the pulmonary valve is less common in adults and may be congenital or acquired; treatment depends on symptoms and right heart function. See Pulmonary valve.

Valve repair (where feasible) is generally favored over replacement when durability and patient-specific anatomy permit. Repair preserves native tissue, maintains more natural valve dynamics, and often reduces the need for long-term anticoagulation. See Valvular repair.

Diagnostic approaches

Initial assessment relies on history and physical examination, with auscultation revealing murmurs that may suggest specific valvular lesions. However, imaging is essential for accurate diagnosis and planning.

  • Echocardiography: The workhorse modality, providing anatomy, valve motion, gradients, chamber sizes, and estimates of function. See Echocardiography.
  • Electrocardiography and chest imaging: Help assess rhythm disturbances and cardiomegaly or pulmonary pressures. See Electrocardiography and Chest radiography.
  • Cardiac MRI and CT: Offer high-resolution anatomy and tissue characterization, particularly when planning surgical or transcatheter interventions. See Cardiac magnetic resonance imaging and Computed tomography.
  • Cardiac catheterization: Sometimes used to measure hemodynamics and assess coronary arteries prior to valve intervention. See Coronary angiography.

Treatment options

Management depends on the specific valve lesion, severity, symptoms, and patient factors such as age and comorbidity.

  • Medical management: Aims to control symptoms and optimize cardiac output. This can include diuretics for fluid overload, afterload-reducing agents where appropriate, rate control for atrial fibrillation, and treatment of associated conditions. See Heart failure and Atrial fibrillation.

  • Valve repair and replacement:

    • Repair is preferred when feasible, as it often preserves more natural valve function and reduces the need for long-term anticoagulation. See Valve repair.
    • Valve replacement uses either mechanical prostheses (durable but require lifelong anticoagulation) or bioprosthetic/prosthetic tissue valves (less need for anticoagulation but limited durability, especially in younger patients). See Mechanical valve and Bioprosthetic valve.

  • Transcatheter therapies: These less-invasive approaches have expanded access, especially in patients who are high risk for surgery.

  • Pediatric and congenital considerations: In children and young adults, decisions about timing and type of intervention must balance durability, growth potential, and the risks of anticoagulation. See Pediatric cardiology and Congenital heart defect.

  • Follow-up and surveillance: Regular imaging and clinical assessment monitor valve function, detect degeneration or recurrence, and guide re-intervention if needed. See Long-term follow-up.

Controversies and debates

The landscape of valve disease management involves ongoing debates about when to intervene, which techniques to use, and how to balance costs with outcomes. These discussions often reflect broader questions about healthcare innovation, access, and value.

  • Open surgery versus transcatheter therapies: For many patients with aortic stenosis or mitral disease, transcatheter approaches offer shorter recovery and expanded eligibility for high-risk patients. Critics caution about long-term durability and the need for future interventions, underscoring the importance of careful patient selection and long-term data. Proponents emphasize reduced hospitalization and quicker return to baseline function, arguing that modern devices perform well in real-world settings. See Transcatheter aortic valve replacement and Surgical aortic valve replacement.

  • Durability and young patients: Mechanical valves last longer but require lifelong anticoagulation with associated bleeding risk; bioprosthetic valves avoid anticoagulation but may degenerate and require reoperation or intervention over time. The choice hinges on age, comorbidity, lifestyle, and risk tolerance. See Mechanical valve and Bioprosthetic valve.

  • Access and costs: New valve technologies can be expensive, and coverage decisions influence who receives cutting-edge therapies. Advocates for broader access argue that higher upfront costs yield long-term savings through fewer hospitalizations and improved quality of life; critics warn against overuse without durable long-term data and risk-adjusted allocation. In any system, value-based care and transparent clinical criteria help ensure that patients who stand to benefit most receive appropriate treatment. See Health economics and Value-based care.

  • Antibiotic prophylaxis and guidelines: Evolving guidelines for prophylaxis around dental and invasive procedures reflect a balance between preventing rare infectious complications and avoiding overtreatment. Clinicians weigh individual risk factors, including prior infective endocarditis, prosthetic valves, and certain congenital lesions. See Infective endocarditis.

  • Innovation versus regulation: The pace of device innovation in valve therapy must be balanced with safety and long-term outcomes. Regulators, clinicians, and manufacturers collaborate to ensure that new devices deliver meaningful patient benefits without compromising safety. See Medical device regulation.

See also