Valvular Insufficiency (Leaking or Regurgitation)

Overview

Valvular insufficiency is a cardiac disease characterized by the failure of one or more of the heart valves to close perfectly resulting blood flowing backwards across the valve (valvular regurgitation or leaking).

The disease may include one or more of the four heart valves:

Left side

  • Aortic valve insufficiency: reverse flow of blood from the aorta into the left ventricle during ventricular diastole.
  • Mitral valve insufficiency: leaking back of blood into the left atrium from the left ventricle thru the mitral valve when the left ventricle contracts (squeezes).

Right side

  • Pulmonary valve insufficiency: backflow of blood from the pulmonary artery into the right ventricle.
  • Tricuspid valve insufficiency: reverse flow of blood from right ventricle into the right atrium during systole.

Individuals with concerns or issues with cardiac valves are either born with the disease (congenital) or acquire it later in life. In some cases, the cause of the disease is unknown.

Congenital

  • Congenital valve disease: more commonly affects the aortic or pulmonic valve with incorrect size, malformation of leaflets and leaflets not attached properly to the annulus. Many patients with previously repaired congenital heart disease develop valve regurgitation later in life. Most patients with repaired Tetralogy of Fallot have severe pulmonary regurgitation that needs to be fixed in teenage years with placement of a pulmonary valve.
  • Bicuspid aortic valve disease: a very common condition affecting 1% of people whereby the aortic valve forms with only two leaflets instead of three. This causes aortic valve function to deteriorate gradually over time resulting in leakage or narrowing (stenosis).
  • Mitral valve prolapse: a floppy mitral valve which eventually stretches over time causing the mitral valve to leak.

Acquired

  • Rheumatic fever: caused by strep throat bacterial infection that causes the immune system to attack the heart valves. It is prevalent in children particularly of indigenous or pacific island nationality and may only appear after 20-40 years.
  • Endocarditis: caused by germs or bacteria that enters the blood stream and damage the valves which leads to holes in the heart valves and scarring.
  • Other possible causes: problems with the heart muscle function that affect the mitral valve (coronary artery disease, heart attack, cardiomyopathy), syphilis (a sexually transmitted disease), hypertension, aortic aneurysms, connective tissue diseases, tumours, some types of drugs and radiation.

Typical symptoms of the heart valve regurgitation include shortness of breath with exertion, dizziness or weakness, pain in your chest, palpitations, and swelling of the abdomen/feet/ankles.

Diagnosis and Treatment

Your GP and Cardiologist will perform a physical exam and may order some blood tests. They may then order some of the following tests:

  • Transthoracic echocardiography
  • Transesophageal echocardiography
  • Cardiac catheterization (also called an angiogram)
  • Radionuclide scans
  • Cardiac magnetic resonance imaging (cMRI)

Depending on the results of the diagnostic tests (which will show the severity level of the disease and its cause), you may either be treated with medication to control or lessen your symptoms. You may also need to undergo open heart surgery to repair or completely replace malfunctioning valves.

If management will be done through medication, here are the typically common medicines that may be given to you:

  • Diuretics (or "water pills")
  • Antiarrhythmic medications
  • Vasodilators
  • ACE inhibitors
  • Beta blockers
  • Anticoagulants ("blood thinners")

Remember to adhere to your doctor's orders when taking medications. Know the names of your medications, what they are for, and how often to take them.

If treatment will be done thru surgery, it may involve repair of the valve or a replacement of the valve thru either open heart surgery or a minimally-invasive heart valve surgical procedure or a less commonly used procedures such as percutaneous balloon valvotomy. Your heart surgeon Dr Orr can provide you with further in depth information about these procedures.

Outline of valve repair/replacement

Pre-operative preparation generally includes:

  • Avoiding eating or drinking anything after midnight on the night before the procedure
  • Bringing all of your medications with you to the hospital
  • Arriving one hour prior to your surgery time.

You will have a pre-admission appointment one to two weeks beforehand, in which you will have routine blood testing and consultation with the anaesthesiologist.

What to Expect

On the day before your procedure, you should receive a call from the hospital. You will be given information about the following day, including where to go and when to arrive. When you arrive, you will be taken to a pre-surgery area so that we can take your temperature, blood pressure, pulse, and listen to your heart and lungs. We will place an intravenous (IV) line in your arm, so that medications may be administered before, during, and after the procedure.

Your procedure may either take a few hours or more, depending on the kind of procedure you will have.  Your family may wait in the Intensive Care Waiting Room.

Recovery

After surgery, you will be taken to the Intensive Care Unit and carefully monitored for at least 1-2 days. In the first few hours you will still be under anesthetic and sleeping. Your breathing will be supported with a ventilator to ensure adequate gas exchange and to prevent pneumonia for a period after surgery. You will have several intravenous lines, a central line in a large vein in your neck and a monitoring line in an artery to measure your blood pressure and take blood samples. You will have a catheter placed in your bladder at the time of the operation to collect and drain all your urine. There will be 1-3 drainage tubes left in your chest at the time of surgery that will be removed 1-3 days after the surgery; they are to remove any blood, fluid or air from your chest cavity after the surgery. There may also be some temporary pacing wires left on your heart and brought out through the chest wall to control and regulate your heart rhythm after the surgery. These are removed by gently pulling them through the skin several days after the operation when they are no longer required. Once your early recovery is complete you will be moved to a step-down area and then to the post-operative ward where you will be getting back on your feet and working with the physiotherapists to clear your lungs and walk.

Before you go home, your nurse will teach you how to use any equipment you might need, how to care for your incision, and review your medications with you. Gradually, over the course of a few weeks, you will regain your strength and be able to return to work and participate in physical activity. You should also participate in the recommended cardiac rehabilitation program where nurses and physiotherapists help you regain your strength and provide education about your heart and lifestyle. Be sure to call your doctor if you notice any of the following:

  • Shortness of breath
  • Swelling
  • Pain
  • Problems with wound healing
  • High temperature
  • Allergic reaction, such as redness, swelling, trouble breathing

Call Dr Orr’s rooms if you have any questions or changes.

  • The Children's Hospital at Westmead
  • Heart Centre for Children- The Children's Hospital at Westmead
  • Sydney Children's Hospital Randwick
  • Westmead Hospital
  • Westmead Private Hospital
  • Royal Australasian College of Surgeons
  • International Society for Heart and Lung Transplantation
  • Sydney Adventist Hospital