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OPD 3, 1st Floor
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There are 4 valves guarding the chambers of the heart, allowing one way flow, and diseases involving these are termed as valvular heart disease. They form a separate group from the diseases of the heart arteries which are the commonest condition affecting adults, and which lead to heart attacks. Valve diseases on the other hand result in pump failure due to disease and damage causing obstruction or leakage in them.
Causes of Valvular Heart Disease
One of the most common conditions affecting the valves of the heart is called as Rheumatic Heart Disease (RHD). This starts as a common throat infection and is caused by a very commonly found bacteria. In some percent of these cases there is a cross reaction with the heart valve and the valves start getting damaged progressively and over the next few years the valve damage becomes severe.
The next common cause of valve disease is degenerative , in which a normal valve starts getting obstructed by deposition of calcium, which prevents its proper opening or closure. This is common with the aortic valve , which guards the outflow of blood from the main pumping chamber, the left ventricle to the major artery the aorta. Sometimes the aortic valve is somewhat structurally abnormal from birth and starts the degenerative process earlier than the normal valve.
Other rarer causes include valve damage by infection, severely abnormal or deformed structure of valve from birth, valve leakage as a result of severe heart muscle weakness, or after heart attacks because of heart enlargement, poor blood supply to the muscle support of the heart valves, or altered geometry of the heart preventing correct alignment and closure of the valves.
Prevalence in India
In our country the commonest cause of valve disease is RHD. The prevalence reported varies, and was earlier estimated as about 6 per 1000, but a recent study last year from AIIMS, in an area near Delhi, suggested prevalence rate of 24 per 1000. This is among the highest in the world and is as much as the poorest countries of Africa. RHD is a socioeconomic disease, the infection being spread by overcrowding, poor hygiene, and also by a low immunity state of malnutrition, frequent infection as well as lack of access to antibiotics, as early treatment and elimination of the infection may limit the disease.
Symptoms and signs and Diagnosis
Unlike heart disease of the arteries which has the usual presentation with chest pain or discomfort, valve diseases usually present as progressive shortness of breath, which finally results in breathlessness or panting even at rest and especially while lying down. A sign of advanced disease is if the patient is woken up at night with severe breathlessness.
Another common symptom is palpitation or rapid pounding of the heart along with the breathlessness and this may be irregular if the patient develops an arrhythmia which is quite common with patients valve disease and signifies advanced disease usually.
A third symptom may be chest pain or exertion as well as exertional fainting and these one especially seen in patients with aortic valve disease.
Diagnosis of valve disease will be made by the doctor after examining the patient for abnormal heart sounds and murmurs which are produced by abnormal jets of blood passing through narrowed valves.
An ECG and X Ray of the chest are done and the most important investigation is the echocardiogram or ultrasound of the heart. This accurately shows the abnormal valve structure, its effects on the heart chambers, and, by using colour and Doppler signals ,accurate measurements of flow and pressure. Even decisions regarding the treatment are made based upon the echo findings.
Prevention of progression of valve disease is done by treating Rheumatic fever by Penicillin and giving all patients with RHD, 3 weekly Penicillin injections to prevent recurrence of the illness. The actual reduction in prevalence of RHD cases comes with improved socio-economic conditions, improved living conditions and sanitation, and, access to better healthcare for the population. In developed countries, the incidence of RHD has declined very significantly, it is a rarity there nowadays.
Salt and fluid restriction is important for valve disease to reduce congestion in the lungs and their symptoms of breathlessness. The medicines provide also relief by reducing the blood volume and controlling the heart rate, both aimed at relief of symptoms.
The most important treatment, however, is surgical repair or replacement of the diseased valve. The timing of this is very important as it should not be left too late or else the heart damage may be irreversible. Also too early surgery may not be needed as the heart can cope for a long time and also an artificial heart valve has its own problems and needs proper care in terms of medicines, blood tests which one needed regularly.
Another exciting development is the artificial heart aortic valve that can be delivered in a catheter and does not need a major surgery which involves opening of the chest. This technique is very exciting and offer an option for elderly patients who have a high surgical risk, and the procedure is carried out in the cardiac cath lab. Several thousand aortic valve replacements by the catheter technique have been done in Europe and USA and the procedure is now getting established in our country.