The treatment of leaking valves
When the valves of the heart fail to seal properly, the blood begins to leak backwards in what is also known as ‘regurgitation’. In this article, consultant cardiologist Dr Jonathan Byrne describes when leaking valves are a cause for concern, and how they can be addressed.
In mild cases, a leaking valve may not have any symptoms or cause problems for the patient. But in more severe cases, the leaking can cause significant damage to the heart and much discomfort to the patient. Symptoms include chest pain, fatigue, heart palpitations, shortness of breath, and swelling in the lower limbs.
What causes a leaking heart valve?
Blood travels through the heart in one direction, and the valves serve to facilitate the flow, preventing backflow by opening and closing with every heartbeat. There are four valves in the heart:
- The mitral valve, where blood flows from the left atrium to the left ventricle.
- The aortic valve, where the blood flows from the left ventricle to the aorta.
- The tricuspid valve, where the blood flows from the right atrium to the right ventricle.
- The pulmonary valve, where the blood flows from the right ventricle to the pulmonary artery.
The valves can become dysfunctional due to heart conditions or congenital defects that mean the muscle doesn’t close completely or the structure of the valve is abnormal (like an irregular number of valve flaps). Such conditions that can cause leaking valves include:
- Cardiomyopathy
- Endocarditis
- Damage from a previous heart attack
- Aneurysm
- Heart tumour
Leaking valves cause strain on the heart and make it less efficient, meaning that it has to pump harder to keep the blood flowing through the body, which can develop into complications such as atrial fibrillation, cardiac arrest, and heart failure.
How are leaking valves treated?
There are a variety of procedures and approaches to treating leaking valves, ranging from medications to major surgeries. Which method is best for a patient will depend on the severity of their symptoms and which of their valves is leaking.
Medicine
Blood pressure medication to reduce the strain on the heart can be beneficial, such as ACE inhibitors or beta-blockers, which work by relaxing the blood vessels to allow more blood to pass through or by slowing down the heart rate. Other medications that may be prescribed include anticoagulants to lower the risk of blood clotting.
Surgery
However, medicines may not be sufficient and the patient will need more intensive treatment such as surgical procedures. Faulty valves can certainly be replaced or repaired, and innovations in the field of cardiac surgery mean that these surgeries can be performed with keyhole / minimally invasive techniques, which are typically less risky, less traumatic, and less invasive procedures – although, they can differ from patient to patient and at times an open procedure may be necessary. Keyhole techniques include:
- Conducting the procedure with the aid of catheters, which are inserted into the blood vessels and fed through them until they reach the leaking valve. This is used specifically for replacements and repairs. Procedures such as mitral transcatheter edge-to-edge repair (TEER), where sutures are placed to bring the valve flaps closer together to prevent leakage, transcatheter aortic valve implantation (TAVR), where a replacement valve is placed within the dysfunctional aortic valve.
- Thoracoscopic surgery, where tools are inserted through small incisions in the side of the chest.
- Robotic assistance, which is similar to thoracoscopy but the tools are mounted onto and operated via a robotic console for optimised precision and dexterity.
Keyhole procedures are fairly common and replace the need for open surgery in many patients.
When repairing the valves, the approach will vary depending on the nature of the dysfunction or deformity of the valve – the flaps of the valve can either be tightened with a ring in what is called an annuloplasty, have any holes patched, reshaped to function better, or any fused flaps can be separated.
Valve replacements involve removing the leaking valve and replacing it with a mechanically manufactured valve or a biological valve from a donor such as a cow, pig, or human.
After a valve repair or replacement surgery, patients will spend around a week recovering in the hospital, fitted with drainage tubes for any fluid build-up in their chest, and monitored closely to ensure the procedure has worked. Patients will be advised when they can go home and return to physical activities.
Patients who have received a mechanical valve replacement will need to take blood thinners for the rest of their lives to avoid blood clots getting stuck in the valve, and those who received a biological one may need a new one after some time as the tissues degrade.
Patients will also be advised to complete a cardiac rehabilitation programme to train their heart and receive education about how to take care of their heart post-surgery.