Valvular Regurgitation

(Regurgitation, Incompetence, Valve Insufficiency)

Also known as valvular incompetence or valvular insufficiency, valvucar regurgitation is a condition in which blood leaks in the wrong direction because one or more of the heart’s valves is closing improperly. Valvular regurgitation may occur in any of the four valves of the heart: the aortic valve, the mitral valve , the tricuspid valve or the pulmonic valve. A valve that is regurgitant, incompetent or “leaky” allows blood to leak back in the wrong direction. Depending on the severity of the leak, there can be as much as two drops of blood that leak backward for every three drops of blood that travel forward. This condition may keep the heart from circulating an adequate amount of blood through the defective valve. To compensate, the left and right ventricles (pumping chambers of the heart) must work harder to get blood to the major arteries and out to the rest of the body and the lungs. As a result, one or both ventricles may eventually be damaged from the increased workload. This damage may be accompanied by myocardial (heart muscle) damage and hypertrophy (thickening and enlargement of the heart). In the most severe cases, valvular regurgitation could lead to heart failure, in which the lungs become swollen (edema).

POTENTIAL CAUSES

Valvular regurgitation may be either congenital (developed before birth) or acquired as a result of conditions such as the following:

·         Myxomatous Degeneration: Often occurring in elderly patients, this is a common cause of valvular regurgitation. It involves a weakening of valve tissue as a result of metabolic changes in the valve, resulting in a loss of tissue elasticity and strength.

·         Rheumatic fever: About 65 percent of rheumatic fever patients develop some form of valvucar heart disease.

·         High blood pressure (hypertension)

·         Heart Failure

·         Pulmonary hypertension (in the case of tricuspid regurgitation)

·         Atherosclerosis

·         An inflammation or infection of the valve (endocarditis)

·         Genetic connective tissue disorders, such as Marfan syndrome connective tissue disorders, such as Marfan syndrome

·         Family history of thee above

 

TYPES OF VALVULAR REGURGITATION

There are four different types of valvular regurgitation, which correspond to the four types of heart valves: aortic regurgitation, mitral regurgitation, tricuspid regurgitation and pulmonary regurgitation.

·         Aortic regurgitation is a condition in which the aortic valve does not close tightly. Because the defective aortic valve is located between the left ventricle and the aorta, this abnormality allows blood to leak back into the left ventricle instead of going into the aorta and out to the rest of the body. As a result, the body receives less oxygen-rich blood and the left ventricle is stretched (dilated) from the extra blood that pours back into it. Furthermore, the pulse tends to be faster and the systolic blood pressure in the aorta tends to be higher. There are two forms of aortic regurgitation: acute and chronic. Acute aortic regurgitation is often a medical emergency. Pumping function, blood flow and blood pressure may be suddenly and significantly lessened, usually due to infective endocarditis. Patients are susceptible to left ventricular dysfunction and heart failure. Chronic aortic regurgitation develops over a period of time during which the ventricles were overworked. Chronic aortic regurgitation is due to scarring from past diseases such as rheumatic fever or endocarditis (an inflammation of the heart lining most often caused by a bacterial infection). The scaring left by these conditions on the heart can affect the function and form of the valves. Other conditions that can contribute to the development of chronic aortic regurgitation include the following:

 

1.       High blood pressure (hypertension)

2.       Advanced age

3.       Marfan Syndrome

4.       Lupus

5.       Collagen deficiencies

6.       Untreated syphilis

 

·         Mitral Regurgitation is a condition in which the mitral valve, located between the left atrium and the left ventricle is defective. As a result, the defective mitral valve allows blood to leak back into the left atrium instead of continuing forward into the left ventricle. The extra blood pours back into the left atrium and can lead to lung congestion. The condition can persist for years without detection, as the heart overworks to compensate of the valvular shortcomings. Eventually, over all cardiac efficiency is reduced. Untreated, the left ventricle muscle can eventually thicken until it falls altogether (heart failure).

CAUSES

i.                     Myxomatous degeneration of the mitral leaflets. A weakening of valve tissue resulting in a loss of tissue elasticity and strength.

ii.                   Dilated, falling left ventricle in which the papillary muscles and chordate supporting the mitral valve fail to allow the valve to close properly.

iii.                  Repeated episodes of cardiac ischemia (in which the heart does not get enough oxygen-rich blood).

iv.                 Scarring due to rheumatic fever or endocarditis.

v.                   Rupture of the chordae fastening the valve to the chamber wall.

vi.                 Tricuspid Regurgitation is a condition in which the tricuspid valve (located between the right atrium and the right ventricle) does not close properly. As a result , blood leaks back into the right atrium. Tricuspid regurgitation is usually a by-product or effect of an underlying condition. It is typically caused by pulmonary hypertension or endocarditis. Heart attack or heart failure can also contribute to this type of valvular disease. Only about 10 percent of the cases of patients with endocarditis involve the tricuspid valve, but this number increases to 50 percent among people who also use intravenous drugs. Because the right ventricle tolerates tricuspid insufficiency relatively well, treatment is aimed at that underlying disease.

vii.                Pulmonary regurgitation is a condition in which the pulmonic valve (located between the right ventricle and the pulmonary artery) does not close properly. As a result, blood leaks back into the right ventricle instead of travelling through the pulmonary artery to the lungs. Depending on how severe this condition is, as well as its cause (e.g., congenital heart defects that lead to high pulmonary artery pressures), signs such as cynaosis (a bluish tint to the skin) could result from not enough blood getting to the lungs to absorb oxygen.

 

SIGNS AND SYMPTOMS

Valvular disease may go unnoticed for years because mild forms tend to produce no symptoms. More severe forms may cause symptoms such as the following:

 

1.       Shortness of breath, sometimes severe and/or in the middle of the night while lying down.

2.       Fatigue , especially during times of increased activity.

3.       Chest pain.

4.       Swelling of the legs, ankles or other parts of the body.

5.       Dizziness

6.       Palpitations

7.       Heavy coughing, sometimes with blood-tinged sputum.

8.       Syncope (fainting) spells.

9.       Cyanosis (a bluish tint to the lips, skin and other areas of the body.

10.   Multiple heart failure symtoms

 

While the symptoms listed above are the problems that patients may bring to their physician’s attention, valvular disease may also produce a number of signs that only the physician will be able to find. These signs are as follows:

·         Heart murmur, as detected by a physician through a stethoscope.

·         Lung Congestion

·         Arrhythmias (abnormal heart rhythms), including atrial fibrillation.

·         Hypotension (low blood pressure).

·         Blood clots.

 

REACHING A DIAGNOSIS

Making the diagnosis of valvular disease will begin with the physician asking about the patient’s full medical history and giving the patient a physical examination. As part of the physical examination, the physician will listen to the patient’s heart through a stethoscope. Telltale murmurs can indicate the location and nature of some valve diseases, such as aortic stenosis a condition in which the sound of the blood flow through the damaged valve is turbulent and distinctive. The sounds of mitral stenosis, tricuspid stenosis and pulmonic stenosis have their own distinctive characteristics. The physician will also listen to the patient’s pulse. Certain murmurs and telltale pulse motion characteristics, such as the “water hammer” pulse, can help physicians determine whether a valve defect is present and, if so, pinpoint its cause and severity. Also as part of the physical examination, the physician will confirm the presence of an abnormal heart rhythm (arrhythmia).

The next diagnostic step will be an electrocardiogram (ECG). This is a recording of the heart’s electrical activity as a graph on a moving strip of paper or video monitor. The highly sensitive electrocardiograph machine helps detect heart irregularities, disease and damage by measuring the heart’s rhythms and electrical impulses. This test can indicate if any of the heart’s chambers are enlarged (the left ventricle in particular) and if arrhythmias are occurring.

If the patient’s history, physical examination and EKG suggest the presence of valvular stenosis, then additional tests will be ordered. Noninvasive tests include the following:

1.       Echocardiogram: Echocardiogram of the heart. This test uses sound waves to visualize the structures and functions of the heart. As moving image of the patient’s beating heart is played on a video screen, where a physician can study and measure the heart’s thickness, size and function. The image also shows the motion pattern and structure of the four heart valves, revealing any potential narrowing (stenosis) or leakage (regurgitation). During this test, color flow Doppler ultrasound will be done to measure the soverity of the valvular stenosis.

2.       Chest x-ray: A radiation-based imaging test that offers the physician a picture of the general size, share and structure of the heart and lungs. An enlarged heart can indicate damage or dysfunction, while congestion of the lungs may indicate heart failure.

3.       Exercise stress test: An ECG id performed while the patient exercises in a controlled manner on a treadmill or stationary bicycle at varied speeds and elevations. The reaction of the heart under exertion can be measured and evaluated, and the functional significance of the valvular stenosis can be assessed.

 

If these noninvasive tests do not offer enough information, then an invasive procedure called a cardiac catheterization may be required. During the cardiac catheterization, pressures will be measured to determine the severity of the stenosis. To measure pressures, one catheter is placed in the left ventricle and another is placed in the pulmonary artery. In conjunction with the blood oxygen samples, these pressure measurements are used to calculate the severity of the stenosis.

 

A coronary angiogram may be done to ensure that the coronary anatomy is normal. In order to perform these tests, the physician injects a special dye (contrast medium) into the coronary arteries through a catheter inserted into the coronary arteries. Then the coronary angiogram can be taken. Following the coronary angiogram, a left ventricular angiogram will be performed. An aortogram may be done to assess aortic regurgitation.

 

Hope you liked this blog!

 

This blog is written by Dr. Bimal Chajjer (Known Heart Specialist)