Aortic Valve Disease

Aortic valve disease affects the valve that controls blood flow from your heart to your body’s main artery. When this valve becomes narrowed or leaky, your heart must work harder to pump blood, which can lead to serious complications if left untreated.

Table of contents

• What is aortic valve disease?
• The aortic valve and its role
• Types of aortic valve disease
• Causes and risk factors
• Symptoms
• Stages of the disease
• How doctors diagnose the condition
• Treatment options
• Lifestyle changes for heart valve health
• Possible complications
• What to expect

What is aortic valve disease?

Aortic valve disease is a type of heart valve disease in which the valve between the lower left heart chamber and the body’s main artery doesn’t work properly^[1]. This condition is the most common form of heart valve disease in developed nations and is also the most dangerous, causing more deaths than any other type of valve disease in the United States^[2].

Aortic valve disease affects about 3% of people older than 65 years^[13]. The condition can stay the same throughout your life without causing problems, or it may slowly get worse until symptoms appear^[12]. Early diagnosis and treatment can be lifesaving^[2].

The aortic valve and its role

The aortic valve sits at the junction between the left ventricle (one of your heart’s four chambers) and the aorta, a large artery that carries blood from the heart to tissues and organs throughout the body^[4]. The valve helps keep blood flowing in the correct direction through the heart^[1].

• Left ventricle
• Aorta

The aortic valve normally has three leaflets, or flaps, that open and close to allow or stop blood from flowing into the aorta^[4]. Each heart valve has flaps of tissue that open and close once per heartbeat, also called cusps^[1]. Your aortic valve is the last one that blood flows through before going out to your body^[10].

Types of aortic valve disease

Aortic valve disease includes several different problems with how the valve works. There are two main types^[2]:

Aortic valve stenosis

In aortic stenosis, the valve opening becomes narrowed or blocked^[2]. Sometimes the aortic valve flaps become thick and stiff, or they connect together. These problems cause the valve opening to become narrow, which reduces or blocks blood flow from the heart to the rest of the body^[1]. The heart has to work harder than usual to pump blood through the smaller opening, and less blood than normal reaches the aorta and the rest of the body^[4].

Aortic valve regurgitation

Aortic regurgitation, also called aortic insufficiency or a “leaky valve,” develops when the valve is unable to fully close^[4]. The aortic valve doesn’t close properly, causing blood to flow backward into the left ventricle^[1]. To compensate for this, the heart must work harder than normal to pump out an adequate supply of blood to the body. Eventually, however, the heart is no longer able to deliver enough blood to the body, which can result in heart failure^[4].

Mixed aortic valve disease

It’s also possible to have mixed aortic valve disease, which means your aortic valve is both narrowed and leaky^[2]. Sometimes stenosis and regurgitation can affect the valve at the same time^[4].

Causes and risk factors

Aortic heart valve disease can be present from birth or it can develop later in life^[4].

Congenital causes

About 1 to 2% of babies are born with a bicuspid aortic valve, meaning the aortic valve only has two cusps instead of the normal three^[4]. In some cases, the bicuspid valve is unable to open fully, leading to aortic stenosis. In other cases, it cannot close completely, resulting in aortic insufficiency. Often, a bicuspid aortic valve does not cause symptoms until adulthood^[4].

Acquired causes

The most common cause of aortic valve disease is wear and tear from aging^[2]. Your valve works hard over the years and eventually starts to break down. As you get older, calcium can build up on your valve flaps. Over time, the calcium makes the flaps grow thick and stiff so they can’t open and shut properly. This is called calcific aortic valve disease, or aortic valve calcification^[2].

Deterioration from wear and tear, and the buildup of calcium in the valve’s leaflets can cause aortic stenosis or insufficiency. Aortic valve disease is most common among older people^[4].

Other causes include^[2]:

• Aortic dissection
• Congenital heart disease
• Endocarditis (infection of the heart)
• High blood pressure
• Radiation therapy to your chest
• Rheumatic heart disease
• Thoracic aortic aneurysm
• Trauma to your chest

Several diseases and infections can cause aortic valve disease, including rheumatic fever, endocarditis, Marfan syndrome, syphilis, rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis, and high blood pressure^[4].

Risk factors

You face a higher risk of aortic valve disease if you^[2]:

• Are over age 60
• Have signs of calcium buildup on your valve
• Were born with a bicuspid aortic valve
• Have a history of rheumatic fever
• Have certain underlying conditions, like Marfan syndrome, Ehlers-Danlos syndrome and lupus
• Underwent radiation therapy to your chest for cancer, like for Hodgkin lymphoma

Symptoms

Early on, you may have no symptoms. People can have aortic valve disease for years without experiencing any problems^[4]. Although survival in people without symptoms is comparable to that in age- and sex-matched control patients, it decreases rapidly after symptoms appear^[13].

As aortic valve disease gets worse, you may experience^[2]:

• Chest pain or discomfort
• Dizziness
• Fainting
• Fatigue
• Heart palpitations
• Shortness of breath with exertion, when lying down or when sleeping
• Swelling in your feet and ankles

Some people who are otherwise healthy may have few or very mild symptoms, even when their valve disease is severe^[7]. Patients should be educated about the importance of promptly reporting symptoms to their physicians^[13].

Stages of the disease

There are four main stages of aortic valve disease. These range from mild to severe and include^[2]:

• Stage A (at risk): Your aortic valve is working fine, but you have at least one risk factor for aortic valve disease. You don’t have symptoms.
• Stage B (progressive): This is mild or moderate aortic valve disease. There are some changes to the valve but it still functions reasonably well.
• Stage C (asymptomatic severe): The valve disease is severe but you don’t have symptoms yet.
• Stage D (symptomatic severe): The valve disease is severe and you have symptoms.

Aortic stenosis has a prolonged latent period, during which progressive worsening of left ventricular outflow obstruction leads to compensatory changes in the heart muscle^[3]. During this time, the heart adapts to maintain adequate blood flow. As aortic stenosis worsens, these adaptations become inadequate to overcome the outflow obstruction and maintain normal heart function^[3].

How doctors diagnose the condition

Healthcare providers diagnose aortic valve disease by doing a physical exam and running some tests^[2]. To diagnose aortic valve disease, a healthcare professional examines you and asks questions about your symptoms and medical history^[9].

Your provider will listen to your heart with a stethoscope. If you have aortic valve stenosis, a sound called a heart murmur may be heard^[8]. A whooshing sound may be heard when listening to the heart with a stethoscope^[9].

Diagnostic tests

You may need several tests, including^[2]:

• Echocardiogram: Sound waves are used to make pictures of the beating heart. An echocardiogram shows how blood flows through the heart and heart valves. It can tell how severe aortic valve stenosis is. The test also can show if the heart muscle is weakened^[8].
• Electrocardiogram (ECG or EKG): This quick test records the electrical activity of the heart. It shows how the heart beats. Sticky patches with sensors go on the chest and sometimes the legs^[8].
• Chest X-ray: A chest X-ray shows the condition of the heart and lungs. It can help determine if the heart is enlarged, which can be a sign of certain types of aortic valve disease or heart failure^[9].
• Cardiac CT scan: A computed tomography scan creates detailed images of the heart.
• Cardiac MRI: A cardiac MRI uses magnetic fields and radio waves to create detailed pictures of the heart. This test may be used to determine the severity of aortic valve disease^[9].
• Heart catheterization: This test examines blood flow through the heart’s arteries.
• Stress test: This may use exercise or medicine to assess heart function under stress.

In people without symptoms, serial Doppler echocardiography is recommended every six to 12 months in patients with severe aortic stenosis, every one to two years in those with moderate disease, and every three to five years in those with mild disease^[13].

Treatment options

Treatment of aortic valve disease depends on how severe the condition is and whether you have symptoms.

Watchful waiting

Watchful waiting is recommended for most patients with no symptoms^[13]. Many people have heart valve defects or disease but don’t have symptoms. The condition may stay the same throughout your life and not cause any problems^[12].

Medicines

Your doctor may prescribe medicines to relieve the symptoms of your heart valve disease, prevent it from getting worse, or treat other heart problems that can affect your heart valves^[12]. These may include:

• Medicines to control high blood pressure, such as diuretics and vasodilators, to ease pressure on the heart
• Medicines to control the heart rate
• Blood thinners to treat or prevent blood clots
• Antibiotics to treat infections that cause heart inflammation or prevent rheumatic fever

ACE inhibitors such as lisinopril are a mainstay of treating all heart failure with reduced ejection fraction, which is the most common clinical consequence of aortic valve disease^[3].

Valve repair and replacement

Aortic valve replacement is the only treatment that improves mortality in patients with symptomatic severe aortic stenosis^[13]. Aortic valve replacement is recommended for most symptomatic patients with evidence of significant aortic stenosis on echocardiography^[13].

Treatment may include surgery to fix or replace the valve. Without treatment, severe aortic valve stenosis can lead to life-threatening complications^[5].

There are two main approaches to valve replacement^[13]:

• Surgical valve replacement: This is the standard of care for patients at low to moderate surgical risk.
• Transcatheter aortic valve replacement (TAVR): This minimally invasive procedure may be considered in patients at high or prohibitive surgical risk. TAVR is a procedure that accesses the heart without open surgery^[14]. The TAVR device is passed along a guidewire using a catheter up to the diseased aortic valve and then deployed and implanted into the existing diseased valve^[14].

Until recently, open-heart surgery had been the standard treatment for significant aortic valve stenosis. However, new treatment options like transcatheter aortic valve replacement have changed how these conditions are treated. These minimally invasive procedures are alternatives to traditional open surgery and can reduce pain, recovery time, and the risk of complications^[6].

When to see a specialist

Cardiology referral is recommended for all patients with symptomatic moderate and severe aortic stenosis, those with severe aortic stenosis without apparent symptoms, and those with left ventricular systolic dysfunction^[13].

Lifestyle changes for heart valve health

Your healthcare provider may recommend healthy lifestyle changes to treat symptoms, which may delay problems^[12]. To maintain a healthy heart and lower the risks of heart disease, there are several healthy lifestyle changes you can make^[15].

Healthy diet

Healthy eating can provide long-term health benefits and reduce the risk of developing chronic diseases, including heart disease^[15]. Your provider may recommend^[12]:

• Choosing heart-healthy foods
• Eating a variety of fruits, vegetables, and whole grains regularly
• Reducing salt, sugar, and alcohol intake
• Avoiding processed foods, specifically processed meat
• Avoiding saturated fat, including animal fat, coconut, and palm oils
• Balancing energy intake and avoiding overeating

Weight management

Aiming for a healthy weight is important^[12]. Being overweight increases the body’s need for oxygen and worsens the effect of any type of valve disease. Reducing weight can delay and occasionally even avoid the need for surgery^[18].

Regular exercise

Getting regular physical activity is recommended^[12]. Regular moderate to high-intensity exercises such as dancing, running, jogging, or speed walking can improve your physical fitness and mental health^[15]. Unless instructed not to by your healthcare professional, it is very important that you maintain physical activity as part of a healthy lifestyle^[18]. Gentle exercise to the extent that makes you mildly short of breath should be encouraged in virtually all heart valve disease patients^[18].

Before starting any exercise program, ask your doctor about what level of physical activity is right for you^[12].

Quit smoking

Managing stress and quitting smoking are important steps^[12]. Smoking or tobacco use is hazardous to almost every organ and is one of the main risk factors for cardiovascular diseases^[15]. There is evidence that smoking increases the rate of progression of aortic stenosis^[18].

Regular checkups

An annual health checkup can help detect telltale signs of potential heart valve diseases or other cardiovascular diseases^[15]. If you begin to have symptoms, consult your doctor for a thorough diagnosis and start a treatment plan or lifestyle modification that can reduce the risk of developing heart disease^[15].

Possible complications

Aortic valve disease is serious and can lead to complications when untreated^[2]. The most common complication is heart failure. This is when your heart can’t pump enough blood to meet your body’s needs^[2].

Other complications include^[2]:

• Abnormal heartbeats (arrhythmias)
• Infection in your heart (infective endocarditis)
• Heart attack
• Stroke
• Sudden cardiac arrest

If left untreated, aortic valve disease can significantly impact quality of life, and can lead to complications like stroke, heart failure, and death^[6].

What to expect

Heart valve disease is a lifelong condition. However, many people have heart valve defects or disease but don’t have symptoms^[12]. Although survival in people without symptoms is comparable to that in age- and sex-matched control patients, it decreases rapidly after symptoms appear^[13].

With proper treatment, people with aortic valve disease can live longer and have a better quality of life. Medicine and surgery can lower your risk of complications and help you live longer^[2]. After repair or replacement, you’ll still need certain medicines and regular checkups with your doctor^[12].

Medical management of conditions that occur alongside aortic valve disease, such as high blood pressure, atrial fibrillation, and coronary artery disease, will lead to optimal outcomes^[13].