Symptoms of Acquired Valve Disease

The symptoms of heart valve disease largely depend on which valve is affected and whether the person has valvular stenosis or valvular insufficiency. Mitral and aortic valves are most commonly damaged, while tricuspid and pulmonary valves are very rarely affected by a pathological process.

Aortic Stenosis

Aortic stenosis prevents the blood from flowing easily from the left ventricle into the aorta which carries the blood to the systemic circulation. In the Western World, aortic stenosis is the most common heart valve disease.

Symptoms of aortic stenosis are determined by the degree of valve stenosis. Mild and even moderate aortic stenosis can be symptom free. Symptoms usually only appear in individuals who have severe aortic stenosis. These symptoms include:

Angina - Angina is one of the first signs of heart failure and which increases the risk of death. If the aortic valve is not replaced, 50% of people with this condition will die in the next 5 years. Angina is the result of left ventricular hypertrophy. The muscle of the left ventricle becomes larger to compensate for the extra work needed to push the blood through the narrow aortic valve. However, the muscles grow much faster than the coronary arteries that supply it with blood and therefore might not receive enough blood to function properly (ischemia). At first ischemia might only occur when the person is doing hard labor. In later stages, however, even during rest, the heart muscle will require more blood than the branches of the coronary artery can supply.

Syncope - Otherwise known as fainting, usually happens due to exertion. It is also indicative of a higher mortality rate. If the aortic valve is not replaced, 50% of people with this condition will die in the next 3 years. The most popular theory as to why a person with aortic stenosis may faint as a result of exercise is that, during exercise, the blood vessels in the skeletal muscles dilate in order to help supply the muscles with more oxygen. This decrease in peripheral vascular resistance is usually covered by an increase in cardiac output. However, the hearts of patients with aortic stenosis cannot do so and this causes the blood pressure to drop and the person faints since the brain is not receiving enough oxygen.

Congestive Heart Failure - The prognosis is grave if the person develops congestive heart failure due to aortic stenosis. 50% of people with this condition will die within 2 years if their aortic valve is not replaced. Congestive heart failure happens as a result of left ventricular hypertrophy followed by fibrosis, as well as by a decrease in the ejection fraction.

Gastrointestinal Bleeding - Recent research has shown that the turbulence inside the stenosed valve destroys the vonWillebrand factor, which is responsible for blood coagulation. Decrease in blood coagulation in turn causes spontaneous bleeding.

Aortic Insufficiency

Aortic insufficiency occurs when the blood flows back from aorta into the left ventricle. Not only can this drastically decrease the diastolic blood pressure, it also overinflates the left ventricle, causing it to work extra hard to compensate.

The main symptoms include:

Orthopnea – starting to suffocate when lying down and being able to breathe well only if the head and shoulders are elevated. This causes paroxysmal nocturnal dyspnea (repeatedly waking up at night gasping for breath).
Dyspnea on exertion – having trouble breathing when performing some sort of physical work.
Angina pectoris and palpitations can also be experienced.
Watson’s Water Hammer Pulse – is a forceful and pounding pulse that rapidly increases and subsequently collapses, since the leaking aortic valve causes the diastolic blood pressure to drop. These pulsing arteries are even noticeable when looking at the patient’s neck.

Mitral Stenosis

As mentioned previously, mitral valve is located between the left atrium and the left ventricle. Mitral stenosis creates an obstruction as the blood is pushed from the left atrium into the left ventricle. Most of the symptoms arise from the fact that left atrium has to perform more work to push the blood through the narrow opening. Over time it leads to hypertrophy (enlargement) of the left atrium. In later stages of the disease, when the left atrium can no longer handle the strain, the volume of the left atrium is increased (dilation) and this leads to further complications.

The most common symptoms of mitral stenosis are:

Heart failure - Overtime, too much strain on the left atrium exhausts its ability to adapt, which first leads to hypertrophy and then to dilation of the left atrium. This increases the blood pressure in the pulmonary capillaries and leads to pulmonary edema as the liquid part of the blood transudates in the alveoli. At first, this causes shortness of breath, cough and fatigue. In later stages, it causes hemoptysis (coughing up blood) and possible respiratory failure.
Atrial fibrillation - In later stages of the disease when the left atrium becomes dilated, the electrical conduction system of the heart may be damaged which may cause atrial fibrillation (rapid non-productive contraction).
Ascites hepatomegaly - Overtime the right side of the heart also becomes involved. The increased blood pressure in the pulmonary capillaries makes it harder for the right side of the heart to pump blood and this eventually leads to right-sided heart failure. This, in turn, increases the blood pressure in the vena cava inferior and the hepatic veins which leads to cardiac cirrhosis and ascites (accumulation of liquid in the abdominal cavity).

Mitral Regurgitation

Mitral regurgitation occurs when the blood flows back through the mitral valve of the left ventricle into the left atrium. This causes the left atrium to become overinflated and, in severe cases, quickly leads to dilation of the left atrium and left sided heart failure and eventually becomes two-sided heart failure.

There are a number of different types of mitral regurgitation:

Acute mitral regurgitation – has the same symptoms as decompensated congestive heart failure:

o Pulmonary edema – occurs due to increased blood pressure in the lung vasculature and transudation of plasma into the alveoli. This causes shortness of breath, fainting and dizziness, non-productive cough and chest pain.

o Paroxysmal nocturnal dyspnea – a condition during which the person begins to suffocate when lying down due to increased blood pressure in the pulmonary circuit. This forces the person to sleep in a half-sitting position with raised head and shoulders.

Compensated mitral regurgitation – can by asymptomatic. There may be no signs of heart failure even when the person performs exercises.
Decompensated mitral regurgitation – the symptoms of decompensated mitral regurgitation are similar to acute mitral regurgitation.

Tricuspid Regurgitation

Tricuspid regurgitation is a condition during which the tricuspid valve allows for some of the blood to flow from the right ventricle into the right atrium. This type of heart valve defect happens in only 1% of cases and is the most common among right-sided heart valve defects. This defect is usually asymptomatic until it becomes right-sided heart failure.

Common symptoms of tricuspid regurgitation include:

Ascites - Right sided heart failure raises the central venous pressure which causes the liquid part of the blood to transudate into the abdominal cavity.
Hepatomegaly – is caused by increased central venous pressure. In some cases, right-sided heart failure leads to congestive hepatopathy (also known as cardiac cirrhosis).
Jugular venous pressure - Due to increased central venous pressure, the jugular veins located on the neck of patient can be clearly seen.

Next chapter: Diagnosis of acquired valve disease