Your heart has four valves. Their job is to make sure blood flows in the right direction and at the right speed throughout the heart. Each of these valves act like doors: They need to be properly formed and flexible, should open all the way so that the right amount of blood can pass through, and should close tightly so that no blood leaks back into the chamber. However, as people age, many of their valves may begin to degenerate and improperly open (stenosis) or improperly close (regurgitation).
Mild or moderate valve disease is usually not a serious problem. However, patients with severe valve disease may require treatment to replace failing heart valves. Yale Medicine Cardiac Surgery performs approximately 200 transcatheter aortic valve replacements (TAVRs) every year—one of the highest numbers in the country.
What causes aortic valve stenosis and regurgitation?
Aortic valve stenosis happens most often because calcium builds up in the aortic valve. The aortic valve is located between the left ventricle and the aorta. This buildup of calcium stops the valve from opening fully and impairs affects the valve by reducing its ability to fully open. This forces the heart to work harder to pump blood to the rest of your body.
Aortic valve regurgitation can happen because of a bacterial infection in the heart (endocarditis), aging or high blood pressure.
What are the risk factors for aortic valve disease?
"Because of the increasing population of elderly baby boomers, and because patients are living longer and more active lives, the prevalence of aortic stenosis is rising," says Dr. Forrest. “The disease primarily affects people 65 years old and older, and 7 percent of people over 65 will develop some degree of aortic stenosis."
“It’s like the hinges of the door getting rusty over time,” he explains.
While aging is the main risk factor, patients can also suffer from aortic valve disease because of a defect from birth. The aortic valve usually is formed with three leaflets—flaps that regulate the blood flow—but some people have only two leaflets, which can lead to earlier problems.
Finally, some untreated infections can lead to rheumatic heart disease, which damages the valve. “We don’t really see this in the United States and other developed countries,” Dr. Forrest says. “Kids now get treated with antibiotics."
What are the symptoms of aortic valve disease?
Mild and moderate aortic valve disease doesn’t usually cause symptoms, says Dr. Forrest. “Initially, even if the valve isn’t working as well as when someone was very young, it’s opening enough to allow adequate blood flow,” he says.
The survival rate for someone with mild to moderate valve disease is no different from someone without it. “There is no indication to fix mild or moderate aortic valve disease that isn’t causing symptoms,” Dr. Forrest says. “You and your physician can monitor it closely.”
As the disease becomes severe, however, symptoms frequently appear. These symptoms include shortness of breath, chest pain, and lightheadedness – to the point, possibly, of passing out. Because there are many ailments that can cause those symptoms, patients should see a primary care physician or cardiologist who can diagnose aortic valve disease – or look into other possible causes.
How is aortic valve disease diagnosed?
Because the improperly functioning valve causes blood to flow erratically, both aortic stenosis and regurgitation causes heart murmur.
“When the stenosis is severe, it's one of the murmurs that’s easy to hear and distinctive,” says Dr. Forrest. “It doesn’t require a fancy test; it just requires the doctor to listen to the heart.”
If the doctor does perceive a strong murmur, the patient gets an ultrasound (an echocardiogram) to confirm the diagnosis and evaluate the degree of stenosis. If the echocardiogram shows severe stenosis but the patient is not symptomatic, then the cardiologist may get the patient moving.
“Patients may not realize that they have symptoms, but you put them on the treadmill, and they get very short of breath,” Dr. Forrest says.
How is aortic valve disease treated?
Aortic valve disease usually isn’t treated until it begins causing symptoms. “Once it’s severe, and you have symptoms, it’s been shown that there is a clear survival benefit to having the valve replaced,” says Dr. Forrest.
The traditional method for fixing the valve is through open heart surgery. The surgeon goes through a patient’s chest wall, removes the old aortic valve and inserts a new valve. For most patients, the recovery time for this type of surgery is several months, as the chest needs time to heal.
A new method of replacing the aortic valve is called transcatheter aortic valve replacement (TAVR). Without requiring open heart surgery or the use of a bypass machine, doctors can insert a valve through an artery in the leg. Through a catheter, the valve can be moved through the artery all the way up to the patient’s heart. Once in position, the valve can be deployed, pushing the old valve out to the side and allowing the new one to function in its place. Recovery time for TAVR is significantly less than for open-heart surgery, as it is a much less-invasive option.
Transcatheter valve replacement started out as an option only for patients who were not surgical candidates, either because of overall frailty, severe calcification in the aorta, or previous heart surgery that made another operation through the sternum difficult. More recently, studies have shown that it’s also a good option for a growing number of patients who can benefit from a less invasive approach.
What are some important innovations in treatment for aortic valve disease?
There have been big improvements in transcatheter aortic valve replacement (TAVR) technology in the past several years. The valves have become easier to insert, and, consequently, the results continue to improve.
Today several valves are available commercially, and still others are in clinical trials. With a variety of valve options – they now vary in their material and in the way they are inserted – doctors can choose the best one for a particular patient.
“Some can help in more challenging situations, and having access to both commercial valves and to the newest valves in clinical studies is a benefit to our patients,” says Dr. Forrest.
Are there any side effects or risks of treatment for aortic valve surgery?
Patients generally recover well from valve surgery, especially from transcatheter aortic valve replacement (TAVR). But all valve surgery—both surgical and transcatheter—does carry risks, including a risk of stroke.
“Any time you’re around aorta with plaque and calcium, there’s always the worry that plaque and debris could come loose and cause a stroke,” says Dr. Forrest. “Each patient’s anatomy is different, and this is one of the reasons why a team approach to the individual patient is so critical.”
What makes Yale Medicine's approach to aortic valve disease unique?
Yale Medicine was the first hospital in the state and one of the earliest in New England to perform transcatheter aortic valve replacement (TAVR) procedures.
Our cardiac surgeons have been performing TAVRs since 2011, and these years of experience have translated into excellent clinical outcomes.
“There’s growing data showing that patients’ outcomes are highly correlated to the experience of the center and the physicians performing the operation,” says Dr. Forrest.
Our doctors take a multidisciplinary approach to every patient. The care team for each cardiac patient involves interventional cardiologists, cardiothoracic surgeons, heart failure specialists, geriatric specialists, cardiac imaging specialists, and anesthesiologists. “This allows us to individualize and tailor the approach for each patient,” Dr. Forrest says. "Customizations might include the type of surgery and even the type of valve to use."