“Leaky Valves”
BY LAWRENCE M. PHILLIPS, MD
A 70-year-old man came to see me in the office the other day. He had been in good health but had noticed that he more easily became short of breath over the prior month.
While listening to his heart, a murmur was heard leading to my performing an ultrasound of his heart, known as an echocardiogram. The echocardiogram showed that there was a large amount of “leaking” of the valve between the top and bottom parts of his heart, known as mitral regurgitation.
Mitral regurgitation is the flow of blood backwards through a closed valve. If a lot of blood flows backwards, it can go all the way back into the blood vessels supplying the lungs. This results in fluid being pushed into the lungs, known as pulmonary edema, which causes shortness of breath. Most mitral regurgitation is found incidentally during an examination. However, when someone is experiencing symptoms, it is usually shortness of breath that leads to the diagnosis.
Listening to the heart with a stethoscope can suggest mitral regurgitation, but the classic way of checking the severity of this regurgitation is by an echocardiogram. This test allows direct viewing of the amount of blood that is leaking backwards as well as the effect that this problem is having on the rest of the heart.
Echocardiograms can also determine the cause of the abnormal flow, including problems with the actual leaflets (the pieces of tissue that make up the valve) and enlargement of the area of the heart holding the valve in place. Depending on the severity of the leaking, follow-up echocardiograms can be performed to look for worsening of the regurgitation.
When the leaking is not severe, medications can be given to minimize the chance of having symptoms. Primarily, these medications act by decreasing a person's blood pressure. The lower the blood pressure, the easier it is for blood to flow forward which results in less backward flow.
Also, water pills can be given to decrease the amount of fluid in the body, which will decrease the chance of fluid overwhelming the lungs. With these two treatments, many people will never reach the point where they need surgical correction of the valve.
The timing of surgery is a big topic of debate. The first reason for surgery is if the patient is having symptoms of shortness of breath with severe leaking. The second reason would be if the blood pressure in the arteries of the lungs become elevated which, as was mentioned above, is a result of all of the backward pressure from the leaking valve. Third, if the heart muscle becomes weaker due to the leaking valve, which is seen on the echocardiogram, then it is time to fix the valve. And there are several other indications for surgery including the development of an irregular heart rhythm called atrial fibrillation with severe mitral regurgitation.
There are two ways that surgery can be performed on the mitral valve: either an attempt can be made to fix the valve or it can be totally replaced. If possible, it is preferred to fix the valve. This is done by putting a ring around the valve (sort of like a tight belt) to keep the parts of the valve closer together.
The other way to fix the valve is to narrow the valve opening by putting a clip or other device in it. If the valve cannot be fixed, then it needs to be replaced. This can be done either with a valve made of animal tissue or with a metal artificial valve. Keep in mind that if a metal valve is used, then a person will have to be on blood thinners (Coumadin) for life.
There is no reason for all patients to have an echocardiogram. However, if you are experiencing symptoms of shortness of breath, it is important that your physician listen to your heart and possibly check an ultrasound of your heart to make sure there are no problems with your heart's valves.
Lawrence Phillips, M.D. is a third year Cardiology fellow at Long Island Jewish Medical Center and North Shore University Hospital. The statements presented here are for information only and do not replace speaking to your own physician.
