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How does a normal heart work?

The heart consists of four chambers. The top two chambers (atria) receive blood while the bottom two chambers (ventricles) pump blood out.

Deoxygenated venous blood returns to the right atrium of the heart. Blood flows from the right atrium to the right ventricle by the opening of the tricuspid valve. Blood is prevented from going backward into the atrium by the closure of the tricuspid valve. The right ventricle then contracts and pumps blood out through the pulmonary valve into the pulmonary artery. The pulmonary valve is closed and the blood is sent to the lungs where it picks up oxygen.

Oxygenated blood returns from the lungs by the pulmonary veins and enters the left atrium. From the left atrium, blood enters the left ventricle by the opening of the mitral valve. Blood is prevented from flowing back into the left atrium by the closure of the mitral valve. Blood is then pumped out the left ventricle to the aorta by the opening of the aortic valve. Blood is prevented from flowing back into the left ventricle by the closure of the aortic valve. From the aorta, oxygenated blood is pumped out to the entire body.

What is it?

Mitral regurgitation is a common valve disorder in which blood flows backwards through the mitral valve during the contraction of the heart and is commonly referred to as a ‘leaky valve’. This reduces the amount of blood flow that is pumped out to the body.

If the leak is small and does not progress, the leak has no significant complication, although severe mitral regurgitation can lead to symptoms of fatigue, breathlessness, and complications.

What are the causes?

The causes of mitral regurgitation include:

  • Mitral valve prolapse- occurs when the mitral valve leaflet tissue is deformed and elongated, therefore the leaflets do not approximate together normally
  • Infective endocarditis- an infection of the heart valves caused by bacteria, fungi, or other organisms. These organisms stick to the heart valves and grow into vegetations. Vegetations prevent the valve from closing properly, allowing blood to leak backwards
  • Rheumatic fever- condition in which bacteria named group A Streptococcus, the bacteria causing Strep throat, goes untreated leading to inflammation of the heart valves
  • Coronary artery disease and Heart attack
  • Trauma- breakage of the chords which hold the mitral valve leaflets in place
  • Congenital heart abnormalities
  • Chronic hypertension (high blood pressure)
  • Heart tumors
  • Mitral annular calcification
  • Systemic lupus erythematosus, Marfan’s syndrome, ankylosing spondylitis
  • Cardiomyopathies

 

 

What happens in mitral regurgitation?

The mitral valve is a funnel-shaped valve with the apex in the left ventricle. The mitral valve consists of two leaflets (cusps) which connect to a ring called the mitral annulus. Heart valves only open in one direction. Once all of the blood has emptied out of the left atrium, the mitral valve tightly closes to ensure no backflow of blood.

In mitral regurgitation the leaflets become weakened, preventing the valve from completely closing, causing a backflow of blood into the left atrium. The complete emptying of oxygenated blood from the left atrium is impaired, increasing pressure in the atrium, pulmonary vessels, and the right side of the heart. A percentage of blood goes from the left ventricle back into the left atrium; therefore blood is limited to fill the rest of the body with oxygenated blood, which can result in symptoms of fatigue and shortness of breath.

 

What are the risk factors?

Several factors can increase the risk of mitral regurgitation.

Risk factors include:

  • Age- by middle age, many people have some mitral regurgitation caused by the normal wear and tear process of the valves. Symptoms are seen in only a small amount of older patients
  • History of mitral valve prolapse or mitral stenosis
  • Previous heart attack
  • History of rheumatic fever and recurrent strep infections
  • Congenital heart defects- born with an abnormal mitral valve

 

What are the symptoms?

Patients with mitral regurgitation may have no symptoms at all. Mitral regurgitation ranges from mild to severe.

Symptoms typically do not occur in mild to moderate mitral regurgitation, or even in severe mitral regurgitation. Symptoms may develop if complications occur.

Symptoms include:

  • Cough
  • Weakness
  • Fatigue
  • Light-headedness
  • Shortness of breath, especially with increased physical activity or when lying flat
  • Swollen feet and ankles (pedal edema)

 

What are the complications?

Structurally, complication arise from damage to the valve itself, as well as the resultant back pressure, causing dilation of the left atrium and increased pressure through the pulmonary vessels

Complications of mitral regurgitation include:

  • Atrial fibrillation
  • Blood clots (systemic thromboembolism)
  • Infective endocarditis
  • Heart failure
  • Pulmonary hypertension

 

 

Call your doctor immediately if you have any of the following:

Call your doctor if you develop symptoms which are suggestive of mitral regurgitation or another problem associated with your heart.

Most signs and symptoms of mitral regurgitation are due its complications, including arrhythmias or heart failure.

These symptoms include:

  • Fatigue
  • Shortness of breath during physical activity
  • Heart palpitations
  • Chest pain

 

 

How is it diagnosed?

Mitral regurgitation is usually diagnosed during a routine visit with your physician.

Diagnosis is based around three parameters including patient history, physical examination, and tests.

 

 

1. Patient history

 

  • Patients may give history of rheumatic fever, although many may not recall a history of rheumatic fever usually because mitral defects manifests later on in life
  • Patients may complain of symptoms of shortness of breath in states with an increased heart rate
  • History of hoarseness of voice may be told due to compression of a nerve by an enlarged heart

 

 

2. Physical examination

 

During a routine physical examination, your health care provider will notice the following:

  • Distended neck veins may be noticed
  • During auscultation a specific type of murmur will be heard caused by the sound of turbulent blood flowing backwards through the mitral valve.

 

 

3. Tests

 

The following tests may be performed:

  • Electrocardiogram (EKG) – a noninvasive test performed in our clinic which determines the electrical activity of your heart. This test may be used to detect left atrial enlargement, and commonly atrial fibrillation.
  • Chest X-ray- a simple test performed in our office showing the size and shape of the heart to determine whether the left atrium is enlarged. Also reveals the presence of fluid in the lungs which may occur due to mitral regurgitation.
  • Cardiac color-Doppler study- use to confirm the presence and determine the severity of mitral regurgitation and cause of mitral regurgitation.
  • Echocardiogram (ECHO)- a noninvasive test using sound waves to determine the size and function of the heart’s chambers and the structure and function of the heart valves.
  • Transesophageal echocardiogram (TEE)

 

 

How is it treated?

Mitral valve regurgitation treatment depends on how severe your condition is.

People with significant (moderate to severe) mitral regurgitation should have routine monitoring to determine if and when treatment is required.

The goal of treatment is to improve the heart function, minimize signs and symptoms and avoid complications.

 

 

Lifestyle modification

Lifestyle modifications are used to minimize the factors contributing to mitral regurgitation (i.e. high blood pressure).

This includes:

  • Salt restriction- a low-salt diet is required to control blood pressure and reduce pulmonary congestion if present
  • Maintain a healthy weight- with a BMI <25
  • Limit alcohol
  • Do not smoke
  • Exercise- for at least 30 minutes a day 5 days a week

The 2006 American College of Cardiology guidelines state that no exercise restrictions are needed for people who have the following:

  • No symptoms of mitral regurgitation
  • Normal heart rhythm
  • Normal size left ventricle and left atrium
  • Normal pulmonary artery pressure

 

 

Medications

Medications will not correct a defective mitral valve, although medications can reduce the symptoms by reducing the workload of the heart and regulating the heart rhythm.

The goal of medical treatment is to reduce the recurrence of rheumatic fever, provide prophylaxis for infective endocarditis, reduce symptoms of pulmonary congestion, control the heart rate and rhythm, and prevent complications.

  • Diuretics- these are sometimes referred to as ‘water pills’ which helps excrete excess water
  • Anticoagulants- these are sometimes referred to as “blood thinners” which prevent blood clots from forming and traveling to other parts of the body
  • Beta blockers- this lowers the heart rate and decreases blood pressure
  • Anti-arrhythmic medications- used to treat atrial fibrillation or other rhythm disturbances associated with mitral regurgitation
  • Cholesterol lowering medications– these act by decreasing the amount of cholesterol in blood, especially Lowering your low density lipoprotein (LDL- your Lousy cholesterol) and keep your high density lipoprotein (HDL- your Healthy cholesterol) High
  • Antibiotics- some patients who have had rheumatic fever may need long-term treatment with penicillin

 

 

Procedures

To treat mitral regurgitation, valve repair or valve replacement may be necessary.

The treatment of choice for people with severe mitral regurgitation is surgical repair or replacement of the mitral valve.

  • Mitral valve repair: repair of the mitral valve is preferred over mitral valve replacement. This procedure improves ventricular function and does not require lifelong therapy with an anticoagulant when compared to valve replacement. During valve repair, the valve will be reshaped to prevent or reduce the backwards flow of blood.
  • Mitral valve replacement: valve replacement is done when repair is not possible. The entire mitral valve will be replaced by a surgeon. A mechanical (metal) or tissue valve (organic) may be used to replace the impaired valve. A mechanical valve requires life-long anticoagulation therapy such as warfarin (Coumadin) to prevent blood clot formation. Tissue valves usually come from a pig or cow. Blood does not clot easily on tissue valves so patients may only need Coumadin or aspirin for only a short time. Tissue valves may wear out faster than mechanical valves and may need to be replaced sooner.

Tissue Valve

Mechanical Valve

 

 

What is the prognosis?

The outcome varies depending on the condition of the patient. Symptoms are usually controlled with medications.

The clinical outcomes are greatly improved in patients with severe mitral regurgitation who undergo surgical or percutaneous interventions.

There is also a risk that the new valve will stop working and may need to be replaced.

 

 

How can I prevent this?

Mitral regurgitation itself often can not be prevented, although some of the complications may be prevented.

  • Prevent rheumatic fever: See a physician when you have a sore throat. Treating strep infections promptly with antibiotics can prevent rheumatic fever that causes mitral regurgitation.
  • Reduce risk factors of coronary artery disease: Lower blood pressure, obesity, high cholesterol, and sugar. It is a good idea to maintain a healthy weight with a BMI below 25.
  • Practice good oral hygiene: gum infections may also cause inflammation of the heart tissue called endocarditis.

What is it?


Mitral valve prolapse (MVP) is a common heart valvular condition in which the mitral valve bulges back into the atrium. This abnormal valve can allow blood to leak backwards from the left ventricle into the left atrium causing what is called mitral regurgitation or a ‘leaky valve’. Mitral valve prolapse is the most common cause of mitral regurgitation.

Minor symptoms such as mild chest pain or palpitations may occur, although it is usually not serious. MVP can progress to serious mitral insufficiency or be associated with serious complications including infective endocarditis and arrhythmias.

Another name for mitral valve prolapse is Barlow’s syndrome or click- murmur syndrome.

 

 

Who is at risk?

Those at risk of mitral valve prolapse include:

  • Thin females between 15-30 years
  • Inheritance or family history of mitral valve prolapse
  • Connective tissue disorders: Marfan’s syndrome; Ehlers-Danlos syndrome; osteogenesis imperfecta; cystic medial necrosis
  • Association with other diseases including: congenital heart diseases (especially atrial septal defect); rheumatic fever; ischemic heart disease; Ebstein’s anomaly; cardiomyopathy; Graves disease; polycystic kidney disease; minor chest wall deformities and scoliosis

 

What happens in mitral valve prolapse?

The mitral valve is a funnel shaped valve with the apex in the left ventricle. The mitral valve consists of two leaflets (cusps) which connect to a ring called the mitral annulus. Heart valves only open in one direction. Once all of the blood has emptied out of the left atrium, the mitral valve tightly closes to ensure no backflow of blood.

In mitral valve prolapse, the valve’s leaflets have extra tissue, prolapsing or bulging like a parachute into the left atrium each time the heart contracts. Bulging of the valve prevents the valve from closing tightly. This can lead to mitral regurgitation which is a backflow of blood due to a leaky valve. A small amount of blood backflow usually does not cause any problems, but severe mitral regurgitation can cause symptoms including shortness of breath, fatigue, lightheadedness or cough.

 

What are the symptoms?

Many people with mitral valve prolapse never have symptoms and only learn about their condition on routine examination.

Symptoms of MVP are typically because of the complications of mitral regurgitation. Symptoms tend to be mild, and develop over time.

Symptoms may include:

  • Chest pain (not caused by coronary artery disease or heart attack) is the most common symptom due to MVP
  • Dizziness or syncope
  • Shortness of breath, especially with increased physical activity or when lying flat
  • Fatigue
  • Palpitations- the sensation of feeling the heart beat
  • Cough
  • Numbness or tingling
  • Panic and anxiety disorders

 

What are the complications?

Complications of mitral valve prolapse include:

  • Mitral regurgitation
  • Infective endocarditis
  • Atrial fibrillation
  • Blood clots (systemic thromboembolism)
  • Stroke

 

 

Call your doctor immediately if you have any of the following:

 

  • Chest discomfort, palpitations, or fainting spells that get worse
  • Long-term illnesses with fever

If you have already been diagnosed with MVP, call your physician if your symptoms worsen.

If you are having chest pain and you are unsure about if it could be a heart attack, seek emergency medical care immediately.

 

 

How is it diagnosed?

Mitral valve prolapse is usually diagnosed during a routine visit with your physician.

Diagnosis is based around three parameters including patient history, physical examination, and tests.

 

1. Patient history

 

  • Family history of mitral valve prolapse or associated conditions
  • Patients may complain of symptoms of shortness of breath in states with an increased heart rate

 

2. Physical examination

 

During a routine physical examination, your health care provider will notice the following:

  • Detect visible skeletal abnormalities
  • During auscultation a specific type of murmur will be heard as a ‘click’ caused by the sound of turbulent blood flowing backwards through the mitral valve.

 

3. Tests

 

The following tests may be performed:

  • Electrocardiogram (EKG) – a noninvasive test performed in our clinic which determines the electrical activity of your heart. This test may be used to detect left atrial enlargement, and commonly atrial fibrillation.
  • Chest X-ray- a simple test performed in our office showing the size and shape of the heart to determine whether the left atrium is enlarged. Also reveals the presence of fluid in the lungs.60481.bmp
  • Cardiac color-Doppler study- use to confirm the presence and determine the severity of mitral regurgitation.
  • Echocardiogram (ECHO)- a noninvasive test using sound waves to determine the size and function of the heart’s chambers and the structure and function of the heart valves.
  • Cardiac catheterization- a hospital procedure used to diagnose the type and severity of your heart condition. A thin tube (catheter) is inserted into an artery in your arm or groin to reach the heart. A contrast dye will be given to view the arteries and seen under x-ray guidance.

 

How is it treated?

Most people with mitral valve prolapse without symptoms do not require treatment.

Symptomatic patients may require medical management or surgery depending on the severity of their condition.

 

 

Medications

Medications will not correct a defective mitral valve, although medications can reduce the symptoms by reducing the workload of the heart and regulating the heart rhythm.

  • Beta blockers- this lowers the heart rate and decreases blood pressure. This helps relieve symptoms of palpitations and chest pain.
  • Anticoagulants- these are sometimes referred to as “blood thinners” which prevent blood clots from forming and traveling to other parts of the body
  • Anti-arrhythmic medications- used to treat atrial fibrillation or other rhythm disturbances associated with mitral regurgitation
  • Diuretics- these are sometimes referred to as ‘water pills’ which helps excrete excess water
  • Aspirin- used to reduce the risk of blood clots, especially in those with a family history of stroke

 

Surgery

 

Most people with mitral valve prolapse do not require surgery. Surgery may be needed for those with severe mitral regurgitation with or without symptoms.

Severe mitral valve prolapse can lead to complications such as heart failure and arrhythmias; therefore surgery is required to relieve symptoms if present and prevent complications.

The treatment of choice for people with severe mitral regurgitation is surgical repair or replacement of the mitral valve.

  • Mitral valve repair: repair of the mitral valve is preferred over mitral valve replacement. This procedure improves ventricular function and does not require lifelong therapy with an anticoagulant when compared to valve replacement. During valve repair, the valve will be reshaped to prevent or reduce the backwards flow of blood.
  • Mitral valve replacement: valve replacement is done when repair is not possible. The entire mitral valve will be replaced by a surgeon. A mechanical (metal) or tissue valve (organic) may be used to replace the impaired valve. A mechanical valve requires life-long anticoagulation therapy such as warfarin (Coumadin) to prevent blood clot formation. Tissue valves usually come from a pig or cow. Blood does not clot easily on tissue valves so patients may only need Coumadin or aspirin for only a short time. Tissue valves may wear out faster than mechanical valves and may need to be replaced sooner.

Tissue Valve

Mechanical Valve

What is the prognosis?

Mitral valve prolapse rarely affects your daily activities. Mild mitral valve prolapse usually does not cause symptoms. If symptoms occur, they can be treated and controlled with medications.

For those who have severe mitral regurgitation, the clinical outcomes are greatly improved for those who undergo surgery.

There is also a risk that the new valve will stop working and may need to be replaced.

 

How can I prevent this?

Mitral valve prolapse itself often can not be prevented, although some of the complications may be prevented.

  • Routine visits to your physician to monitor your condition and/or progression of your condition.
  • Reduce risk factors of coronary artery disease: Lower blood pressure, obesity, high cholesterol, and sugar. It is a good idea to maintain a healthy weight with a BMI below 25.
  • Practice good oral hygiene: gum infections may also cause inflammation of the heart tissue called endocarditis.

What is it?


Mitral stenosis is a condition in which the mitral valve narrows and prevents the valve from completely opening. This abnormal valve blocks blood flow from the left atrium coming into the left ventricle, the main pumping chamber of the heart.

The obstruction of blood flow results in an increased pressure in the left atrium and everything before the left atrium.

 

What are the causes?

The causes of mitral stenosis include:

  • Rheumatic Heart Disease– this is the most common cause of mitral stenosis which is a complication of strep throat. Rheumatic fever is the cause in about 70% of all patients with mitral stenosis. Valvular problems develop about 20 years after the onset of rheumatic fever.

Rare causes include:

  • Congenital heart defect- born with a narrowed mitral valve and prone to early valve stenosis
  • Malignant carcinoid disease
  • Autoimmune disease- systemic lupus erythematosus (SLE), rheumatoid arthritis
  • Genetic disorders- Fabry disease, Hunter syndrome
  • Infectious causes- Whipple disease, infectious endocarditis
  • Endomyocardial fibrosis
  • Mitral annular calcification

 

 

 

What happens in mitral stenosis?

The mitral valve is a funnel shaped valve with the apex in the left ventricle. The mitral valve consists of two leaflets (cusps) which connect to a ring called the mitral annulus. Heart valves only open in one direction. Once all of the blood has emptied out of the left atrium, the mitral valve tightly closes to ensure no backflow of blood.

In mitral stenosis, the leaflets become thickened or calcified preventing the valve from completely opening. The thickening of the leaflets make the valve opening narrowed. The ejection of blood from the left atrium struggles to get through the narrowed opening. The complete emptying of oxygenated blood from the left atrium is limited, increasing pressure in the atrium, pulmonary vasculature, and the right side of the heart. Limiting of blood from entering the ventricle to fill the rest of the body with oxygenated blood can result in symptoms of fatigue and shortness of breath.

 

What are the risk factors?

 

  • Antibiotics: Mitral valve stenosis is less common than it was years ago because rheumatic fever is now rare in the United States. Rheumatic fever is more common in countries where antibiotics are not used.
  • History of rheumatic fever and recurrent strep infections
  • Chest radiation
  • Medications- ergot preparations used for migraines

 

 

What are the symptoms?

Patients with mitral stenosis may have no symptoms at all. Mitral stenosis ranges from mild to severe. Symptoms typically develop in severe mitral stenosis.

Symptoms include:

  • Fatigue, especially with increased physical activity
  • Shortness of breath, especially with increased physical activity or when lying flat
  • Swollen feet and ankles (pedal edema)
  • Heart palpitations (fluttering sensation in the chest)
  • Frequent respiratory infections such as bronchitis
  • Cough, possibly bloody (hemoptysis)
  • Chest pain or discomfort (rare)- increases with activity, decreases with rest; radiates to the arm, neck, jaw, or other areas; tightness, pressure, squeezing constricting

 

 

How is it classified?

Mitral stenosis is classified as:

  • Mild- valve area 1.6- 2.5cm2 and/or transvalvular gradient <5 mmHg
  • Moderate- valve area 1.1- 1.5cm2 and/or transvalvular gradient 6- 10 mmHg
  • Severe- valve area  ≤1cm2 and/or transvalvular gradient ≥10 mmHg

 Normal- valve area 4.0- 6.0cm2 with no transvalvular gradient

 

 

What are the complications?

Complications of mitral stenosis include:

  • Atrial fibrillation
  • Blood clots (systemic thromboembolism)
  • Pulmonary edema
  • Heart failure
  • Pulmonary hypertension

 

 

Call your doctor immediately if you have any of the following:

Call your doctor if you develop symptoms such as:

  • Fatigue
  • Shortness of breath during physical activity
  • Heart palpitations
  • Chest pain

 

How is it diagnosed?

Mitral stenosis is usually diagnosed during a routine visit with your physician.

Diagnosis is based around three parameters including patient history, physical examination, and tests.

 

 

1. Patient history

 

  • Patients may give history of rheumatic fever, although many may not recall a history of rheumatic fever usually because mitral stenosis manifests during the third or fourth decade of life
  • Patients may complain of symptoms of shortness of breath in states with an increased heart rate
  • History of hoarseness of voice may be told due to compression of a nerve by an enlarged heart
  • History of severe cough that may be blood tinged (hemoptysis)

 

 

 

2. Physical examination

 

During a routine physical examination, your health care provider will notice the following:

  • Distended neck veins may be noticed
  • During auscultation a murmur may be heard that makes a distinct snapping sound

 

 

3. Tests

 

The following tests may be performed:

  • Electrocardiogram (EKG) – a noninvasive test performed in our clinic which determines the electrical activity of your heart. This test may be used to detect left atrial enlargement, and commonly atrial fibrillation.
  • Chest X-ray- a simple test performed in our office showing the size and shape of the heart to determine whether the left atrium is enlarged. Also reveals the presence of fluid in the lungs which may occur due to mitral stenosis.
  • Echocardiogram (ECHO)- a noninvasive test using sound waves to determine the size and function of the heart’s chambers and the structure and function of the heart valves.
  • Cardiac catheterization- a hospital procedure used to diagnose the type and severity of your heart condition. A thin tube (catheter) is inserted into an artery in your arm or groin to reach the heart. A contrast dye will be given to view the arteries and seen under x-ray guidance. This allows the physician to see any abnormalities in the arteries including blockage that may coexist with mitral stenosis.

 

 

How is it treated?

Treatments to prevent permanent damage to the heart from mitral stenosis include lifestyle modification, medications and invasive procedures.

 

 

Lifestyle modification

 

  • Salt restriction- a low-salt diet is required if pulmonary congestion is present
  • Maintain a healthy weight- with a BMI <25
  • Exercise- for at least 30 minutes a day 5 days a week
  • Limit alcohol
  • Do not smoke

 

 

Medications

Medications will not correct a defective mitral valve, although medications can reduce the symptoms by reducing the workload of the heart and regulating the heart rhythm.

The goal of medical treatment is to reduce the recurrence of rheumatic fever, provide prophylaxis for infective endocarditis, reduce symptoms of pulmonary congestion, control the heart rate and rhythm, and prevent complications.

  • Diuretics- these are sometimes referred to as ‘water pills’ which helps excrete excess water
  • Anticoagulants- these are sometimes referred to as “blood thinners” which prevent blood clots from forming and traveling to other parts of the body
  • Beta blockers- this lowers the heart rate and decreases blood pressure
  • Anti-arrhythmic medications- used to treat atrial fibrillation or other rhythm disturbances associated with mitral stenosis
  • Cholesterol lowering medications– these act by decreasing the amount of cholesterol in blood, especially Lowering your low density lipoprotein (LDL- your Lousy cholesterol) and keep your high density lipoprotein (HDL- your Healthy cholesterol) High. Used to slow the progression of rheumatic mitral stenosis
  • Antibiotics- some patients who have had rheumatic fever may need long-term treatment with penicillin

 

 

Procedures

To treat mitral stenosis, valve repair or valve replacement may be necessary. Both surgical and non-surgical options are available.

  • Percutaneous mitral balloon valvuloplasty (PMBV) – this is a non-surgical procedure done in a hospital setting. The catheter is positioned into the narrowed mitral valve and the balloon-tipped catheter is inflated. The balloon pushes the mitral valve open and stretches the valve opening, improving blood flow. Balloon valvuloplasty may relieve mitral valve stenosis and symptoms, although re-stenosis of the valve is common.

Surgical approach involves:

  • Mitral valve replacement- is the primary treatment for severe mitral stenosis. The entire mitral valve will be replaced by a surgeon. A mechanical (metal) or tissue valve (organic) may be used to replace the stenotic valve. A mechanical valve requires life-long anticoagulation therapy such as warfarin (Coumadin) to prevent blood clot formation. Tissue valves usually come from a pig or cow. Blood does not clot easily on tissue valves so patients may only need Coumadin or aspirin for only a short time. Tissue valves may wear out faster than mechanical valves and may need to be replaced sooner.

 

Tissue Valve

Mechanical Valve

 

What is the prognosis?

Without treatment, an individual with mitral stenosis with symptoms or complications may do poorly.

The clinical outcomes are greatly improved in patients who undergo surgical or percutaneous interventions. However, longevity is still shortened due to the complications of the disease process.

There is also a risk that the new valve will stop working and may need to be replaced.

 

 

How can I prevent this?

Mitral stenosis itself often can not be prevented, although some of the complications may be prevented.

  • Prevent rheumatic fever: See a physician when you have a sore throat. Treating strep infections promptly with antibiotics can prevent rheumatic fever that causes mitral stenosis.
  • Reduce risk factors of coronary artery disease: Lower blood pressure, obesity, high cholesterol, and sugar. It is a good idea to maintain a healthy weight with a BMI below 25.
  • Practice good oral hygiene: gum infections may also cause inflammation of the heart tissue called endocarditis.

What is it?

Infective (bacterial) endocarditis is an infection of either the heart’s inner lining (endocardium) or the heart valves.

Infective endocarditis (IE) is uncommon, although some individuals with heart conditions may be at greater risk of developing IE.

 

 

What are the causes?

Infective endocarditis (IE) is caused by:

  • Bacteria i.e. streptococci and staphylococci (most common)
  • Rickettsia
  • Fungus (rare)

 

 

How does it occur?

Certain bacteria are normally found in the oral cavity, upper respiratory tract, intestines, urinary tract and skin.

For any reason, these bacteria can enter the blood stream and cause what is called bacteremia. This infected blood flows through the body and can settle on abnormal or damaged heart valves or endocardium. The bacteria in the blood begin to damage the heart valves. Bacteria can start collecting and piling up on these damaged valves to form what is called vegetations. Vegetations can further disrupt blood flow through the heart valves.

Bacteremia is common after many invasive procedures including dental or surgical procedures.

 

 

Who is at risk?

Those at risk of developing infective endocarditis include:

  • Individuals with damaged valves or those with a damaged endothelium caused by high pressures jets of blood due to septal defects (congenital heart defects), valve stenosis, or valve regurgitation may be at higher risk of IE
  • Following cardiac surgery using prosthetic valves and other prosthetic material or intraoperative infection
  • Intravenous drug users
  • Previous history of endocarditis

If you have any of the above conditions, you may need to take antibiotics before certain dental or surgical procedures for prophylactic treatment.

If you are at risk of IE, maintaining good oral hygiene is essential for prevention.

Antibiotics before dental procedures are only recommended for patients with the highest risk of infected endocarditis and who would gain the most from IE prevention.

 

 

Recommended regimens:

A single dose of antibiotic prophylaxis should be administered before the patient’s procedure.

If not possible before, prophylaxis can be administered up to 2 hours after the procedure.

 

 

A. Patients undergoing cardiac surgery

 

  • A dental evaluation and treatment is recommended before cardiac valvular surgery or the replacement/repair of CAD. This decreases the incidence of late prosthetic valve endocarditis.
  • Patients who are undergoing prosthetic heart valve surgery or prosthetic intravascular/ intracardiac materials are at risk of developing infection. Prophylactic antibiotics are recommended for these procedures because the morbidity and mortality risk and infection are high.

Antibiotic prophylaxis is not required in patients who have undergone coronary artery bypass graft surgery or percutaneous intervention with stent implantation.

 

B. Dental procedures

 

  • Antibiotic prophylaxis is recommended for patients undergoing dental procedures involving the gingival tissue or periapical region of a tooth who has at least one of the following conditions:

– Prosthetic heart valve

– Previous infective endocarditis

– Congenital heart disease

– Heart transplantation recipients who have developed cardiac valvulopathy

 

 

C. Respiratory tract procedures

 

  • Many respiratory tract procedures cause transient bacteremia with an array of organisms, although there is no supporting data demonstrating the link between procedures and IE.

The AHA does not recommend antibiotic prophylaxis for bronchoscopy unless the procedure involves an incision of the respiratory tract mucosa.

 

 

D. Gastrointestinal (GI) or Genitourinary (GU) tract

 

  • Enterococci is a normal bacteria found in the intestinal flora. During an infection of the GI tract, enterococci are likely to cause infective endocarditis.

The AHA does not recommend prophylactic antibiotics to prevent IE for patients undergoing GI or GU procedures. There is no supporting data showing that the administration of prophylactic antibiotics for GI or GU procedures prevents infective endocarditis.

Indications for Subacute Bacterial Endocarditis prophylaxis:

 

Antimicrobial prophylaxis is indicated for patients with ‘High Risk’ conditions who are undergoing dental and other procedures.

High risk patients have a greater risk of developing an adverse outcome if Infective Endocarditis were to occur.

As per new regulation, patients with the following conditions require prophylaxis:

  • Prosthetic heart valves, including bioprosthetic and homograft valves.
  • Prosthetic material used for cardiac valve repair
  • Prior history of infective endocarditis
  • Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits.
  • Completely repaired congenital heart defects with prosthetic material or device, whether placed by surgery or catheter intervention, during the first 6 months after the procedure.
  • Repaired congenital heart disease with residual defects at the site or adjacent to the site of the prosthetic device.
  • Cardiac valvulopathy in a transplanted heart.

Prophylaxis is No longer indicated in patients with common valvular lesions including:

  • Bicuspid aortic valve
  • Acquired aortic or mitral valve disease (including mitral valve prolapsed with regurgitation)
  • Hypertrophic cardiomyopathy with latent or resting obstruction

The choice of antibiotic is patient and procedure specific.

Dental Procedure: For patients undergoing dental procedure, in majority of individuals is 2mg Amoxicillin orally 30-60 minutes before the procedure. Patients allergic to amoxicillin can be treated with Cephalexin (2g) or Azithromycin or Clarithromycin (500mg) or Clindamycin (600mg).

Non-Dental Procedures: Most patients require amoxicillin or alternative antibiotic therapy.

What is it?

Aortic stenosis is a condition in which the aortic valve narrows and prevents the valve from completely opening. This restricts blood flow out of the aorta and heart. Restriction of blood flow exiting the aorta diminishes the body’s potential to receive the maximum amount of oxygen rich blood.

Over time the pressure increases in the left ventricle forcing the left ventricular wall to work harder and eventually become thicker and weaker. Weakening of the heart muscle can lead to the development of symptoms including weakness and fatigue.

What are the causes?

Narrowing of the aortic valve may be caused by the following:

  • Congenital heart defects: unicuspid or bicuspid aortic valve
  • Calcification
  • Rheumatic fever- a condition that may develop after strep throat with valvular disease developing 5-10 years after rheumatic fever occurs
  • Type II hyperlipoproteinemia

Rare causes include:

  • Fabry’s disease
  • Systemic lupus erythematosis (SLE)
  • Paget disease
  • Alkaptonuria

How does a normal heart work?

The heart consists of four chambers. The top two chambers (atria) receive blood while the bottom two chambers (ventricles) pump blood out.

Deoxygenated venous blood returns to the right atrium of the heart. Blood flows from the right atrium to the right ventricle by the opening of the tricuspid valve. Blood is prevented from going backwards into the atrium by the closure of the tricuspid valve. The right ventricle then contracts and pumps blood out through the pulmonary valve into the pulmonary artery. The pulmonary valve is closed and the blood is sent to the lungs where it picks up oxygen.

Oxygenated blood returns from the lungs by the pulmonary veins and enters the left atrium. From the left atrium, blood enters the left ventricle by the opening of the mitral valve. Blood is prevented from flowing back into the left atrium by the closure of the mitral valve. Blood is then pumped out the left ventricle to the aorta by the opening of the aortic valve. Blood is prevented from flowing back into the left ventricle by the closure of the aortic valve. From the aorta, oxygenated blood is pumped out to the entire body.

What happens in aortic stenosis?

The aortic valve consists of three leaflets (cusps) which connect to the aorta by a ring called the annulus. Heart valves only open in one direction. Once all of the blood has emptied out of the left ventricle, the aortic valve tightly closes to ensure no backflow of blood.

In aortic stenosis, the leaflets become thickened or calcified preventing the valve to completely open. The thickening of the leaflets make the valve opening narrowed. The ejection of blood from the left ventricle struggles to get through the narrowed opening. The complete emptying of oxygenated blood from the left ventricle is limited, increasing pressure in the ventricle and eventually thickens the wall of the left ventricle.

The limiting of blood flow into the aorta results in symptoms of breathlessness, dizziness, and loss of consciousness.

What are the risk factors?

Aortic stenosis is not considered a preventable disease, yet some risk factors include:

  • Congenital abnormalities: bicuspid aortic valve (born with two aortic leaflets)
  • Age: increasing age along with calcium deposits on valves
  • History of rheumatic fever: causes leaflets to thicken, stiffen, or fuse
  • Hypertension (high blood pressure)
  • Hypercholesterolemia (high cholesterol)
  • Diabetes (high glucose)

What are the symptoms?

Patients with aortic stenosis may have no symptoms at all.

Aortic stenosis ranges from mild to severe. Symptoms typically develop in severe aortic stenosis.

Symptoms include:

  • Shortness of breath with activity
  • Angina (chest pain)
  • Fainting, weakness, or dizziness
  • Fatigue
  • Palpitations (sensation of feeling a rapid heart beat)

How is it classified?

Aortic stenosis is classified as:

  • Mild- valve area 1.1-1.9cm2 and/or transvalvular gradient <30 mmHg
  • Moderate- valve area 0.8- 1.1cm2 and/or transvalvular gradient 30-50 mmHg
  • Severe- valve area 0.8- 1cm2 and/or transvalvular gradient >40 mmHg

 Normal valve area: 3.0- 4.0cm2 with no transvalvular gradient

What are the complications?

Complications of aortic stenosis include:

  • Angina
  • Syncope
  • Left ventricular hypertrophy
  • Heart failure
  • Arrhythmias
  • Endocarditis
  • Cardiac arrest

Call your doctor immediately if you have any of the following:

  • Chest pain or shortness of breath
  • Weakness in the muscles of your face, arms, or legs
  • Difficulty in speaking
  • Rapid or bounding heartbeat
  • Fainting or dizziness

How is it diagnosed?

Aortic stenosis is usually diagnosed during a routine visit with your physician.

Diagnosis is based around three parameters including patient history, physical examination, and tests.

1. Patient history

Patients may complain of symptoms in severe aortic stenosis.

Symptoms of:

  • Angina
  • Dizziness
  • Syncope
  • Loss of breath

2. Physical examination

During a routine physical examination, your health care provider will notice the following:

  • Faint pulse may be felt
  • Changes in the quality of pulse in the neck
  • During auscultation a murmur may be heard

3. Tests

The following tests may be performed:

  • Electrocardiogram (EKG) – a noninvasive test performed in our clinic which determines the electrical activity of your heart. This test may be used to detect left ventricular hypertrophy (thickening) which may occur due to aortic stenosis.
  • Chest X-ray- a simple test performed in our office showing the size and shape of the heart to determine whether the left ventricle is enlarged. Also reveals the presence of fluid in the lungs which may occur due to aortic stenosis.
  • Echocardiogram (ECHO)- a noninvasive test using sound waves to determine the size and function of the heart’s chambers and the structure and function of the heart valves.
  • Cardiac catheterization- a hospital procedure used to diagnose the type and severity of your heart condition. A thin tube (catheter) is inserted into an artery in your arm or groin to reach the heart. A contrast dye will be given to view the arteries and seen under x-ray guidance. This allows the physician to see any abnormalities in the arteries including blockage that may coexist with aortic stenosis.

How is it treated?

Lifestyle changes are implemented in patients diagnosed with aortic stenosis to stop the progression of the disease.

Treatment of aortic stenosis is primarily done with surgical intervention, although medications can be used to relieve symptoms of aortic stenosis.

Lifestyle modifications

Lifestyle modifications help reduce the work load on the heart.

Lifestyle modifications include:

  • Maintain a healthy weight with a BMI <25
  • Limit salt intake
  • Maintain cholesterol, sugar, and blood pressure
  • Exercise for at least 30 minutes a day 5 days a week
  • Stay physically active
  • Do not smoke!

Medications

Medications are used to reduce symptoms and control heart rhythm disturbances associated with aortic stenosis.

Medications may be used to lower blood pressure or cholesterol.

  • Cholesterol lowering medications– these act by decreasing the amount of cholesterol in blood, especially Lowering your low density lipoprotein (LDL- your Lousy cholesterol) and keep your high density lipoprotein (HDL- your Healthy cholesterol) High.
  • Beta blockers- this lowers the heart rate and decreases blood pressure.
  • Diuretics- these are sometimes referred to as ‘water pills’ which helps excrete excess water.
  • Antibiotics- people who had rheumatic fever in the past may require long-term treatment with penicillin.

Surgical Procedures

Surgical valve repair or valve replacement is preferred in patients who develop symptoms; even if symptoms are not bad, surgery is still recommended.

Aortic valve replacement offers substantial improvement of symptoms and life expectancy. The only effective treatment for severe aortic stenosis is aortic valve replacement.

Therapies to repair or replace the aortic valve include:

  • Balloon valvuloplasty- in a hospital setting, the physician inserts a thin tube (catheter) tipped with a balloon into an artery in the leg or arm to reach the heart. The catheter is positioned into the narrowed aortic valve and the balloon-tipped catheter is inflated. The balloon pushes the aortic valve open and stretches the valve opening, improving blood flow. Balloon valvuloplasty may relieve aortic valve stenosis and symptoms, although re-stenosis of the valve is common.
  • Aortic valve replacement- is the primary treatment for severe aortic stenosis. The entire aortic valve will be replaced by a surgeon. A mechanical (metal) or tissue valve (organic) may be used to replace the stenotic valve. A mechanical valve requires life-long anticoagulation therapy such as warfarin (Coumadin) to prevent blood clot formation. Tissue valves usually come from a pig or cow. Blood does not clot easily on tissue valves so patients may only need Coumadin or aspirin for only a short time. Tissue valves may wear out faster than mechanical valves and may need to be replaced sooner.

 

  • Transcatheter aortic valve implantation (TAVI) – this is a less invasive approach for aortic valve replacement with a prosthetic valve. The approach can be transfemoral (femoral artery in leg) or transapical (apex of heart). TAVI approach is reserved for patients who are at an increased risk of complication from aortic valve surgery.

What is the prognosis?

Without treatment, an individual with aortic stenosis with symptoms or complications may do poorly.

Aortic stenosis can be cured with surgery although there is a risk for arrhythmias (irregular heart rhythm) which may cause sudden death. There is also a risk that the new valve will stop working and may need to be replaced.

How can I prevent this?

Aortic stenosis itself often can not be prevented, although some of the complications may be prevented.

  • Prevent rheumatic fever: See a physician when you have a sore throat. Treating strep infections promptly with antibiotics can prevent rheumatic fever that causes aortic stenosis.
  • Reduce risk factors of coronary artery disease: Lower blood pressure, obesity, high cholesterol, and sugar. It is a good idea to maintain a healthy weight with a BMI below 25.
  • Practice good oral hygiene: gum infections may also cause inflammation of the heart tissue called endocarditis.

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