Millions of Americans – around 2.5% of the population – have heart valve disease. This happens when one or more of the heart’s four valves don’t work properly.
Valve disease affects young and old patients and can be diagnosed in anyone.
Whether caused by age, an infection or another heart condition, diseased heart valves often have one of three problems:
Regurgitation (leakage): Also known as backflow, this occurs when the valve doesn’t close tightly. Blood will leak back into the chamber rather than flowing through the heart or into an artery.
This is most often caused by prolapse when the valve flaps flop or bulge back into the upper heart chamber during a heartbeat.
Stenosis: This occurs when the flaps of a heart valve thicken, stiffen or calcify. This prevents the valve from fully opening, limiting blood flow.
Atresia: This congenital heart defect occurs when a heart valve does not develop normally and has insufficient valve leaflets or narrowing.
Treatments for valve disease can be different for each valve, and options are constantly evolving over time with emerging clinical trials and research.
While most patients require some form of surgically or minimally invasive treatment, providers may recommend nonsurgical treatment for some patients.
This can depend on your age, health, condition and symptoms.
Here, Gorav Ailawadi, M.D, M.B.A., chair of cardiac surgery, director of the University of Michigan Health Frankel Cardiovascular Center and a leader in surgical and transcatheter treatments for valve disease, answers questions about different treatment options.
Mitral valve disease
What’s the most common form of mitral valve disease?
Ailawadi: For mitral valve disease, the main condition we see is regurgitation, with stenosis being the second most common.
There are two main categories of regurgitation; the first is degenerative mitral disease, which occurs from prolapse or flail of the leaflets.
The other category we see is secondary, or functional, mitral disease. This often comes after a heart attack, which causes the heart to stretch and leads to leakage even though the valve does not have any abnormality itself.
Mitral valve disease can often go undetected for years. Patients most commonly feel shortness of breath — particularly with exertion — fatigue or an irregular heartbeat.
Can mitral valve disease be treated with medical therapy?
Ailawadi: For patients with secondary mitral disease, medical therapy is the first line of treatment.
We call this goal-directed medical therapy and will treat patients with a whole class of medications, including diuretics, beta blockers and sometimes ACE and SGLT2 inhibitors.
We will work with heart failure cardiologists to optimize medications. Roughly one-third of patients get better with medical therapy.
Still, medical therapy is not often enough and often patients need more invasive treatments.
What are the surgical options for mitral valve disease?
Ailawadi: With degenerative mitral valve regurgitation, we typically use a surgical approach given the excellent short and long term results.
The most common treatment for a leaking mitral valve is now repairing rather than replacing. For mitral valve stenosis, surgery to replace the valve is the main technique because it often cannot be repaired.
Both repair and replacement of the mitral valve can require open-heart surgery.
However, some institutions, like ours, offer a minimally invasive surgical approach that involves access between the ribs without breaking bones and allows for more rapid recovery.
With this approach, we use a heart-lung machine to circulate blood throughout the body just like with standard open-heart surgery.
Our surgical repair rate is extremely high in patients who have mitral valve degeneration. For replacement, we will implant an artificial valve (either bioprosthetic or mechanical) to ensure that blood flows normally.
Open-heart surgery does carry some risks, like atrial fibrillation.
However, open-heart surgery is the treatment of choice for many patients with mitral valve prolapse, since it leads to complete elimination of valve leak and yields better long term outcomes. In healthy patients, the risk of mortality with surgery is less than 1%.
What are the least invasive options for mitral valve disease?
Ailawadi: There are percutaneous ways to repair and replace a diseased mitral valve. They are often targeted for higher risk patients that are too sick for surgery. Those patients are usually older and have multiple chronic conditions.
First option is repairing the mitral valve with a catheter that is inserted into a vein in the groin and guided to the heart.
The physician then inserts a device through the catheter to clip and fasten the leaflets together, helping prevent that valve leakage when it closes.
This is called transcatheter edge-to-edge repair, or TEER, which is a form of transcatheter mitral valve repair, also called TMVr.
There are two TEER devices available: MitraClip and PASCAL, both of which are approved by the FDA for high risk patients.
In addition, we have two ongoing trials to assess doing this procedure percutaneously through the groin using special clips to address the leakage in medium and low risk patients.
When the valve can’t be repaired, there are options for transcatheter mitral valve replacement, or TMVR. This can be done through the groin or with a small incision in the chest.
Here, we replace the valve entirely. The doctor will deliver a collapsible prosthetic valve through the catheter and deploy and replace the patient’s own mitral valve.
Aortic valve disease
What is the most common form of aortic valve disease?
Ailawadi: By far, aortic stenosis is the most common valve disease that we see. With normal wear-and-tear, calcium can build up on the valve preventing it from opening. This occurs in nearly 10% of patients over 80 years old.
Younger patients who develop aortic stenosis often have bicuspid aortic valve disease, a common congenital defect that 1% of the population is born with, where the aortic valve has two leaflets instead of the normal three.
Although less common, we are seeing more patients with aortic valve regurgitation. This can commonly be associated with aortic aneurysm.
Many people with aortic valve disease early on don’t experience any symptoms but may notice a general decline in activity level as the disease progresses.
As the valve gets worse, the most common symptoms patients feel are shortness of breath, chest tightness, lightheadedness and fatigue.
Can aortic valve disease be treated with medical therapy?
Ailawadi: While some medications may be prescribed to control symptoms and prevent further damage, aortic valve disease is either treated surgically or percutaneously.
What is the surgical option for aortic valve disease?
Ailawadi: The decision of when and how to have aortic valve replacement requires input from a multidisciplinary team.
At our Comprehensive Aortic Program, experts from different sub-specialties will come together to determine a customized treatment plan that may include minimally invasive treatments or open surgery.
For aortic stenosis, open surgical aortic valve replacement, or SAVR, is the treatment of choice for young, healthy patients.
Patients with aortic regurgitation can often have their valve surgically repaired, which requires a unique expertise only some centers have. Otherwise, leaking aortic valves require replacement.
These are done through an open-heart sternotomy or partial sternotomy approach where the heart-lung machine is used.
Replacement valve choices that we offer include artificial valves (either prosthetic or mechanical) or the Ross procedure (using the patient’s pulmonary valve for the aortic valve). Surgical valves can last 12-20-plus years.
Our surgeons have developed a novel way to enlarge the space to put larger valves in, which is associated with better long term survival.
Are there less invasive options for aortic valve disease?
Ailawadi: Over a decade ago, studies investigated transcatheter aortic valve replacement, or TAVR. With this, a collapsed valve on a stent is inserted through the groin or neck then deployed to push away the diseased valve.
Our experts were involved in the earliest stages of those trials and now have some of the largest experience.
TAVR is now the dominant form of aortic valve replacement in the United States for severe aortic stenosis patients in both low and high risk patients.
To decide whether to offer SAVR or TAVR, a multidisciplinary team works with each individual patient to determine what will give the best immediate result and how we will manage if they need more procedures in the decades to come.
Some conditions, like endocarditis or aneurysms, can preclude a patient from TAVR eligibility. We try to limit the number of procedures patients would need while weighing their risks for each procedure.
Although there are no long term studies on TAVR, some research suggests they can last eight-plus years.
Ongoing trials are looking even longer term. We are also leading a new TAVR valve trial with unique features that can help with longevity.
Tricuspid valve disease
What is the most common form of tricuspid valve disease?
Ailawadi: The vast majority of tricuspid cases we see are due to regurgitation.
This is often in patients with other diseases that cause the right side of the heart to dilate. In addition, around 40% of patients with severe tricuspid regurgitation have a pacemaker in place.
The leads in those pacemakers go across the tricuspid valve and can cause them to open up years after the pacemaker is placed.
Tricuspid valve disease often occurs with mitral or aortic valve disease. This disease is a lot more subtle when it occurs in isolation. Mostly patients will feel like they have “no gas in the tank” with exertion.
Diagnosis often happens late in the disease. Patients can be sick with poor kidney or liver function by the time they get referred to us.
The risks are much better if we can treat patients earlier before the right heart gets weak or the liver/ kidneys get affected.
Can tricuspid valve disease be treated with medical therapy?
Ailawadi: The only known medical treatments for the tricuspid valve are diuretics and treatment of atrial fibrillation. In some patients, these medical treatments can dramatically improve tricuspid regurgitation.
However, when there is persistent severe tricuspid regurgitation, we often need to intervene either with surgery or transcatheter options.
What are the surgical options for tricuspid valve disease?
Ailawadi: For tricuspid regurgitation, we can repair the leaking valve by putting a small, synthetic ring around the valve to tighten it.
We can also replace it with an artificial tissue valve, which we do in patients with advanced regurgitation or tricuspid stenosis. Traditionally, this is an open-heart procedure or a minimally invasive surgery going through the rib cage.
Over the last three years, we have treated many more patients than in the past. We have seen outcomes with surgery improve.
In fact, nearly 80% of patients are alive and well three years after valve replacement, which is remarkable given how sick these patients are coming in.
Are there less invasive options for tricuspid valve disease?
Ailawadi: Because mortality is higher in tricuspid surgery, there is a huge push for less invasive options. In addition to minimally invasive surgery, there are a number of transcatheter trials going on, most of which we are participating in.
These include TEER (TriClip, PASCAL) and a transcatheter bioprosthetic valve replacement (EVOQUE, Intrepid) delivered percutaneously through the femoral vein.
We have extensive experience with these devices and trials.
Pulmonary valve disease
What is the most common form of pulmonary valve disease?
Ailawadi: Pulmonary valve disease tends to be patients with congenital heart disease.
When a child has pulmonary stenosis, the area where the blood exit’s the heart’s right ventricle is too narrow. The problem is often caused by fusion of the valve leaflets. This can make it harder for the heart to pump blood to the lungs.
Milder stenosis can eventually cause shortness of breath with exercise and low stamina. If left untreated, it can weaken the heart muscles and cause heart failure symptoms.
Commonly, the pulmonary valve can also leak, adding stress to the right ventricle. This, again, is common after congenital surgery as children age.
Can pulmonary valve disease be treated with medical therapy?
Ailawadi: There are limited medical therapies for the pulmonary valve. They mostly revolve around diuretic therapy.
What is the surgical option for pulmonary valve disease?
Ailawadi: Surgical repair of this valve is often preferred when there is more extensive narrowing. In addition to the valve replacement, we may need to place a patch to enlarge the narrowed area from the right ventricle to the pulmonary artery.
Are there less invasive options for pulmonary valve disease?
Ailawadi: Balloon angioplasty has shown to be an excellent option.
Using a catheter, the tip is placed across the pulmonary valve and inflated to gently dilate the narrowed area. This can buy time in the way of years before a valve replacement may be needed.
Over the last 10 years, we have developed extensive expertise in transcatheter pulmonary valve replacement. There are now commercially available devices to treat this, and many patients who needed surgery may be eligible for this approach.
Why are clinical trials so important when it comes to treating valve disease?
Ailawadi: When a patient is older or sicker, they may not be a candidate for surgery. In addition, many people, not just non-surgical candidates, are looking for lower risk, minimally invasive options. The best way for anyone to avoid a surgery is to participate in a trial.
These trials allow us to examine potentially groundbreaking innovations in the world of valve disease treatment. There are three major benefits for patients in clinical trials:
- They give patients access to new devices that can be revolutionary, potentially avoiding major surgery.
- Patients get extra benefits of follow-up from valve experts yearly. Multiple studies have shown even patients in a control arm (or even placebo arms) live longer when they are in clinical trials due to the extra attention they get.
- They can help patients in the future and change health care for humanity.
How can you learn about clinical trials?
Call (800) 962-3555 to search for a clinical trial.
Written by Noah Fromson.
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