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Structural Heart Disease

  • Defects or disorders in the heart's structure that are present at birth or develop later
  • Sometimes no symptoms in the early stages, but chest pain and fatigue an be warning signs
  • While some cases still require open surgery, catheterization is making care easier for many patients
  • Involves structural heart disease program
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Overview

If you are eating healthy and hitting the gym, you’re doing important work toward preventing coronary heart disease, which is caused by plaque buildup in the arteries that can cause chest pain and even heart attack. Structural heart disease is a different problem. It’s a term commonly used to describe defects or disorders in the heart’s structure—its valves, for instance.

A heart problem that is structural may be congenital, meaning it was present at birth, or it can result from aging or underlying diseases causing wear and tear on the heart later in life.

The good news is that treatments for structural heart disease are improving. While open heart surgery may still be the best solution in some cases, minimally invasive catheter-based therapies have made care easier on patients, with fewer complications and quicker recoveries.

“This is a field that’s rapidly developing,” says John Forrest, MD, a cardiologist and director of the Yale Medicine Structural Heart Disease Program. “By providing patients with therapies they otherwise wouldn’t be able to access, we can help improve not only their survival but also their quality of life.” 

How does structural heart disease affect the heart?

For the heart to pump blood effectively, four heart valves must open and close so that blood can travel in the appropriate direction. They are the aortic, mitral, tricuspid, and pulmonic valves, and they must open and close in harmony for the blood to flow properly. 

“You can think of it like moving through the rooms of a house,” Dr. Forrest says. “The doors have to open and close to allow people to walk through in an organized manner. If a heart valve doesn’t open well, it’s like a rusty door that is hard to open and get through. Or a valve can become regurgitant, meaning it doesn’t close all the way, so the blood starts flowing in the wrong direction.”

Sometimes these problems develop during pregnancy. Advanced imaging technology now allows doctors to diagnose structural heart problems in a developing fetus. Many of these babies have surgery to fix a defect in the first days or years of life.

Adults also can develop a structural heart defect, sometimes as a side effect of another disease, such as atherosclerosis, high blood pressure, an infection, rheumatic fever, or bacterial endocarditis (an infection of the inner layer of the heart and valves). A defect may be associated with damage caused by a previous heart attack, or it may simply be a result of aging.

Some specific structural conditions include the following:

Mitral valve regurgitation or stenosis: Regurgitation is a backflow of blood when the valve doesn’t close properly. Stenosis is when a valve’s leaflets thicken or stiffen or, in some cases, fuse together, preventing some of the blood from flowing through.

Aortic stenosis: This occurs when the valve between the heart and the aorta, the main artery carrying blood from the heart to the rest of the body, does not open well.

Coarctation of the aorta: This can be a mild to severe narrowing that develops in part of the aorta, the largest artery in the body.

Ventricular septal defects: This is a hole in the wall that separates the heart’s two lower chambers. It can cause improper blood flow, and if it is too large, force the heart and lungs to work too hard.

How are structural heart defects diagnosed?

Structural heart problems in adults may have no symptoms in the early stages. As structural heart disease progresses, you may have one or more of the following signs and symptoms:

  • Chest pain
  • Irregular heartbeats
  • Shortness of breath
  • Lightheadedness or passing out
  • Swelling of the abdomen, ankles, or feet
  • High blood pressure
  • Fatigue
  • Kidney dysfunction

Many structural heart defects are detected at or before birth with a sophisticated imaging technique called fetal echocardiography that uses sound waves to create a picture of a baby’s heart. Most defects can be treated after the baby is born.

Structural heart disease can be more difficult to detect later in adulthood. Heart defects can run in families, so alert your doctor if a close relative had this type of heart condition. Sometimes a doctor will notice a problem, such as a heart murmur, by listening to the heart through a stethoscope.

When a doctor suspects structural heart disease in an adult, he or she will use a variety of tests to make the diagnosis. These may include an echocardiogram and/or magnetic resonance imaging (MRI) of the heart, a chest X-ray to look at the heart’s shape, and an electrocardiogram to assess the heart’s rhythm. In some cases, your doctor may perform a catheterization procedure to identify places where blood vessels are blocked or narrowed. 

How are structural heart defects and disorders treated?

Some structural problems may never require treatment, although they will need to be monitored throughout a patient’s life. Some patients may benefit from medication. For example, a doctor may prescribe warfarin, a common blood thinning medication, if blood clots pose a particular risk for a patient.

In some serious cases—for instance, a complicated valve replacement is called for or a patient needs a heart transplant—open heart surgery may be required.

However, in a growing number of cases, cardiologists treat structural heart defects through a catheter-based approach—a minimally invasive alternative to surgery. The doctor numbs the area where the catheter will be inserted, usually in the groin, and provides sedation to help the patient relax. Through the catheter, the doctor is able to either repair or replace the defective valve.

How is Yale Medicine unique in the care of structural heart disease?

Yale Medicine’s Structural Heart Program was the first integrated program of its kind in Connecticut dedicated to the care of adult patients with complex structural heart and valve disease. It is the largest program of its kind in the state and has been recognized as a national leader in the field, treating an increasing number of complex cardiac conditions through catheter-based and minimally invasive procedures.

The program is known for its percutaneous (through the skin) valve program, including aortic, mitral, and pulmonic valve procedures. The physicians at Yale Medicine have led multiple national and international studies that have led to recent advances in the field, and continue to pioneer new strategies for these transcatheter therapies.

“We have new devices and new techniques that are coming out on an almost monthly basis,” Dr. Forrest says. “By using the most cutting-edge techniques, we can provide therapies to our patients, which otherwise wouldn't be available to them, that improve not only their survival, but also their quality of life.”