Complex Valve Disorder

Physicians and staff of MHI are recognized for the quality of care provided for patients who have valve disease. The following outlines the current state of valve disease treatment at the Minneapolis Heart Institute at Abbott Northwestern Hospital including volumes of cases, outcomes when available and existing programs.

• Abbott Northwestern Hospital is JCAHO accredited by the Joint Commission on Accreditation of Healthcare Organizations.
• Abbott Northwestern Hospital has been consistently included in the list of America’s best hospitals published by US News & World Report. The score is based on reputation, mortality and other factors.
• In addition, Abbott Northwestern Hospital was named one of the nation’s top 100 cardiovascular hospitals by Solucient in 2005 for the fifth time since 1999.

Teaching program

The Minneapolis Heart Institute and Abbott Northwestern Hospital have been part of the cardiology training program for the University of Minnesota’s cardiology fellows since 1999. As noted in the New England Journal of Medicine, teaching hospitals provide the ideal environment for state-of-the-art treatment and evidence-based care.

Board Certification

Each cardiologist and cardiac surgeon on staff at the Minneapolis Heart Institute is board certified or board eligible

Research

The Minneapolis Heart Institute participates in research studies in conjunction with the Minneapolis Heart Institute Foundation.

Volumes

• The Abbott Northwestern Hospital/Minneapolis Heart Institute echo lab performs more than 20,000 echos annually.
• More than 1,000 transesophageal echos.
• Cardiac catheterizations – more than 7,000 annually.
• Surgical volume 1000 total cardiac surgeries.
• More than 1400 cardiac MRI
• More than 1500 cardiac CTs
• Mortality data for valve surgery is lower than the national average mortality

Physicians and other providers may use words such as “stenosis” or “regurgitation” when speaking of valves. The following helps define these terms:

• Stenosis – occurs when the leaflets do not let enough blood through the valve and may be caused from a thickening, stiffening or fusion of the leaflets. Severe valve stenosis forces the heart to work harder to pump blood. Mild to moderate degrees of stenosis generally do not result in significant impairment.
• Regurgitation – may ensue when a valve doesn’t shut completely and blood leaks backwards instead of moving forward. This can result in the heart working harder and becoming enlarged and weakened. The result is that the blood pumps less blood than normal. In general, mild and moderate leakages do not lead to excess work for the heart. However when the regurgitation is severe, symptoms can result from the blood traveling the wrong direction.

Valve disease can be attributed to several different causes. The following are the most common types of valve diseases:

Congenital (develops before birth) – incorrect formation of the valve(s) before a child is born which most commonly affects the aortic and pulmonary valves.

• Bicuspid aortic valve – the most common congenital malformation in which only two leaflets are present instead of three, which may result in stenosis or regurgitation.
• Myxomatous valve disease – a weakening of the valve tissue usually affecting the mitral valve. A condition in which stretching of the leaflets and the chordea occurs resulting in “floppy” leaflets. An example of this is mitral valve prolapse or may be seen in individuals with Marfan’s Syndrome.

Infections –

• Rheumatic fever, a result of untreated streptococcal infections, usually occurs in those 5 to 15 years of age but the ramifications aren’t usually seen until 20 to 40 years after the infection occurs. There is an autoimmune response that results in the leaflets becoming thicker, harder and shorter.
• Endocarditis – infection/inflammation of the lining of the valves from bacteria that enters the blood stream. The results can be holes, scarring, growths and/or a leaky valve. Bacteria can enter into the body at any time but particularly through dental procedures, any type of surgery, IV drug usage or any other serious infection. Individuals who have valve disease are at higher risk of endocarditis.

Those with valve dysfunction may experience the following symptoms:

• Shortness of breath –during rest, sleep (sleeping propped up on a pillow) or activity
• Light-headed, dizzy or fainting
• Chest pain or chest discomfort – the feeling that something is sitting on their chest or squeezing of the chest
• Light headedness, passing out (syncope)
• Tiredness, fatigue, decreased endurance
• Swelling of the feet, stomach or abdomen
• Weight gain of 2 to 3 pounds in a day

If you are noticing these symptoms, you should contact your primary care provider. Your provider can decide if these symptoms require further testing. Some people with valve disease do not notice any symptoms at all.

Diagnosis of Heart Valve Disease

In order to diagnose valve disease, you will need to discuss your symptoms with your provider. There may or may not be symptoms from a heart valve abnormality, and it may be detected during a physical exam. The way the blood flows across the valve changes and this will sound different when a provider listens with a stethoscope. A provider may then obtain a diagnostic test in order to confirm diagnosis and to evaluate the extent of the valve disease. The following tests are those that you may experience:

1. Echocardiogram

2. Transesophogeal Echocardiogram (TEE)

3. Cardiac MRI

Valve diseases can prevent a heart valve from opening fully or closing tightly. This means less blood gets through the open valve, while some blood escapes between chambers from the closed valve. Valve disease strains the heart, making it work harder to meet the body’s needs. Valve disease can also lead to further heart complications. When a valve is no longer functioning properly it may need to be replaced or repaired. Both surgical and non-surgical treatments may treat valve disease.

Medical Treatments

Unlike other cardiac conditions there are no good medicines available to treat valve disease in isolation. Every patient with diagnosed valve disease requires antibiotics prophylaxis. However, patients may require medicines for conditions which may coexist with valve disease. For example high blood pressure usually needs to be treated well in patients with regurgitant valves. Also, medicines for heart failure are needed when the left ventricle (pumping chamber) is not working properly or in patients with congestive heart failure. Aortic insufficiency is the only valve disease that has proven medical treatment. Particular care must be taken in prescribing drugs in patients with coexistent valve disease.

Surgical Treatments

Valve repair involves making your original valve better able to open and close properly. Sometimes, this involves patching holes or tears in the valve or widening the valve opening to permit the valve to close appropriately.

If a surgeon cannot repair a heart valve, a valve replacement may be needed. Valve replacement involves replacing your valve with a mechanical valve or a tissue valve. Your physician will talk with you about the benefits of each kind of valve

Choose the following link for more information on Valve Repair & Replacement procedures at the Minneapolis Heart Institute.

• Mechanical Valve: a mechanical valve is a prosthetic valve that is designed to work like a healthy valve. A mechanical valve replacement requires a person to take blood thinners (an anticoagulation medication) like warfarin to prevent blood clots from developing on the valve.
• Tissue Valves: a tissue valve is a valve that came from an animal. The tissue is chemically treated prior to being placed in a person.

Non-surgical Treatment

Occasionally surgery is not an option for a patient with severe stenotic (stiff) valve disease. Or a patient may be too frail or simply may not want to undergo open-heart surgery. In that case, balloon aortic valvuloplasty (BAV) may be an option. In balloon aortic valvuloplasty, a catheter with a balloon on the end of it is threaded through the blood vessels to the valve. The balloon is inflated and deflated several times in order to break up the deposits and allow the valve to open more normally. The balloon is then removed.

Valvuloplasty – a procedure that makes the leaflets close tightly so that blood does not back up into the atriums.

• Commissurotomy is a specific type of valvuloplasty and is used when the leaflets have become stiff resulting in fusion of the leaflets at the base of the valve. An inflated balloon is used to split the leaflets, which enables the valve to function properly.
• Annuloplasty – a procedure to prevent blood from backing up in the atrium by repairing the fibrous tissue at the base (annulus) of the valve.

See the Complex Heart Valve Disorders Program brochure. (Adobe Reader is required; click on the "Get Acrobat Reader" button below to open a new window to the Adobe Web site, and to download free software.)

(Adobe Reader is required; click on the 'Get Acrobat Reader' button above to open a new window to the Adobe Web Site and to download free software.)

• Vib R. Kshettry, MD
• Kevin M. Harris, MD, FACC, FASE
• Wesley R. Pedersen, MD, FACC