Category Archives: Heart Valve Diseases

Tricuspid Valve Diseases

Acquired tricuspid valve disease is a rare condition. The tricuspid valve is a valve with three leaflets that controls the flow of blood from the right atrium to the right ventricle.
The most common cause of tricuspid stenosis and regurgitation is rheumatic heart disease.

Tricuspid Stenosis

Although tricuspid stenosis is usually due to rheumatic causes, connective tissue diseases can also rarely cause tricuspid stenosis. Symptoms of tricuspid stenosis usually appear in the forties. The most common symptoms are fatigue, dyspnea, and peripheral edema. Almost half of the patients suffer from arrhythmia, atrial fibrillation. In very advanced stages of the disease, liver enlargement and ascites (buildup of fluid in the abdomen) may occur.

Tricuspid Regurgitation

Tricuspid regurgitation alone is a rare condition. It is often associated with other valvular diseases. Rheumatic heart disease and endocarditis are the most common causes of this disorder. Atrial fibrillation is present in the majority of patients with tricuspid regurgitation. Symptoms of the disease appear late. The jugular veins become prominent, and the liver enlarges. Dyspnea is not common.

Surgery Indications

Surgical valve repair or valve replacement may be required for severe tricuspid or pulmonary valve regurgitation and right ventricular failure. When hemodynamically significant pulmonary or tricuspid valve stenosis is also present with limiting symptoms, it can sometimes be treated by valve replacement or repair.

Surgical Treatment

If the cause of tricuspid stenosis is adhesion between the valves, just opening this adhesion sometimes can solve the problem. In cases of tricuspid regurgitation, repair of the enlarged valve ring with a ring (annular graft material) and plication of the enlarged valve (narrowing by suturing) can be used. In cases where the valve is severely degenerated, it should be replaced with an artificial valve.

Pulmonary Valve Diseases

The pulmonary valve is located at the outlet of the right ventricle. It regulates the flow of blood from the right ventricle into the pulmonary artery. Pulmonary valve stenosis is usually congenital. In adults, it rarely occurs as a symptom of other diseases. Mild stenosis is usually not a problem, while moderate to severe ones require surgical treatment.

Cyanosis (bruising) in the jugular veins are the main symptoms of pulmonary stenosis.

Pulmonary regurgitation is a very rare condition and usually causes no symptoms. Pulmonary regurgitation can occur as a result of chronic lung disease or diseases that cause increased pressure in the pulmonary vessels. Control of pulmonary hypertension can correct valvular regurgitation.

In rare cases, severe pulmonary regurgitation is noted, requiring treatment. Infective endocarditis occurs more readily in patients with pulmonary regurgitation. For this reason, caution is advised, and antibiotics should be used even before simple surgical procedures such as dental treatment.

Mitral Valve Diseases

Mitral Valve

The mitral valve is a structure that regulates blood flow between the atrium and the ventricle on the left side of the heart. While it opens during the resting phase of the heart (diastole) to allow blood to flow from the left atrium to the left ventricle, it closes during systole, preventing blood from flowing back. The mitral valve is essentially made up of four components.

1. Leaflets
2. Mitral annulus
3. Papillary muscles (muscles that allow the valve function)
4. Tendinous cords (string-like structures that attach the leaflets to the papillary muscles)

Mitral Stenosis

In many patients with mitral stenosis, the cause is chronic rheumatic disease. A rheumatic valve lesion may cause stenosis or mitral regurgitation or both. While regurgitation alone is more common in early childhood, stenosis is more common in young adults, and both are common in older adults. Mitral stenosis obstructs the flow of blood from the left atrium to the left ventricle.

Mitral Regurgitation

Unlike mitral stenosis, it may occur for many different reasons.

a) Enlargement of the valve annulus due to Marfan syndrome, Ehlers-Danlos syndrome, or ventricular dilatation
b) Thickening and retraction of the valve because of rheumatic disease and inability of the valve to close tightly.
c) Impairment of valve closure due to shortening of the chordae due to rheumatic disease or elongation of the chordae due to degenerative disease
d) Rupture of the papillary muscles after acute myocardial infarction for ischemic reasons

Clinical Course and Symptoms of Mitral Valve Diseases

The most prominent symptom is dyspnea (shortness of breath) accompanied by an increase in left atrial pressure and, correspondingly, pulmonary venous pressure and pulmonary capillary pressure. The patient’s exercise tolerance is reduced, and he/she quickly becomes fatigued. These symptoms often appear after a very long time. However, in acute cases, the patient may present to the clinic with the picture of pulmonary edema.
When listening to a stenotic valve, the opening sound can be heard as S1 and a diastolic murmur in the mitral focus. An enlarged left atrium is usually seen on a posterior-anterior chest radiograph. Echocardiogram is the most informative preoperative examination. Angiography is required only in patients in whom the information on ECHO is considered insufficient and in patients with ECG findings suggestive of coronary artery disease. Even if the ECG is normal in patients older than 40 years, angiography is required.

Surgery Indications

The course of disease in mitral stenosis is usually slow. The first symptoms usually appear 7-10 years after rheumatic fever. It usually takes another 10 years for the main symptoms to appear. However, the clinical course varies from person to person.

Exercise capacity is important in the evaluation and treatment of all valvular heart disease. For this reason, the New York Heart Association (NYHA) functional classification is used. Patients’ exercise capacities, as determined by testing, are assessed using a measure called MET (1 MET = 3.5 ml/kg/min is the relative oxygen consumption of activity)

NYHA class 1: No complaints (7 MET or higher).
NYHA class 2: Complaints with vigorous activity (5-6 METs).
NYHA class 3: Complaints even with simple daily activities (2-4 METs).
NYHA class 4: Complaints even at rest.

Accordingly, surgery is indicated in patients with NYHA class II (if atrial fibrillation is present), NYHA class III, and NYHA class IV.

The development of atrial fibrillation (arrhythmia) not only worsens the patient’s symptoms, but also increases the risk of thromboembolism (when a blood clot forms in the heart and is carried by the bloodstream, clogging other blood vessels of organs, arms and legs).

Some criteria in the echocardiogram are also used to decide on surgery. (e.g., valve area)

Mitral Regurgitation

The clinical course of mitral regurgitation is almost the same as that of mitral stenosis. However, tacitly progressive left ventricular dysfunction masks the symptoms of mitral regurgitation for a long time. The patient’s clinical condition and ECO findings are evaluated together for the indication of surgery.

Surgical Treatment

Closed mitral commissurotomy is an obsolete surgical procedure. It is based on the principle of dilating the valve by reaching the valve narrowed by adhesion through the ventricle with bougies.

Reparative Surgeries

All procedures are usually performed under anesthesia as median sternotomy (opening of the sternum), cardiopulmonary bypass (a machine temporarily takes over the function of the heart and lungs) and opening of the left atrium.

– Repair of a papillary muscle tear
– Shortening the elongated chorda or lengthening the short chorda.
– Repair of the enlarged valve annulus with a flexible Teflon ring support.

These are the main reparative procedures. However, in some cases, valve repair procedures are not sufficient to correct the pathology. Then the valve must be replaced with a prosthetic valve. Mechanical valves with a Teflon (PTFE) coated surface are often used. The success of the treatment depends on the experience and technical equipment of the surgical team, but also on the preoperative condition of the patient, whether other pathology is present, and the suitability of the prosthesis. To avoid clots on a prosthetic valve, these patients should take anticoagulant medication for life.

Aortic Valve Diseases

AORTIC VALVE DISEASES

The aortic valve is located at the left ventricular outlet of the heart. It controls the flow of blood from the heart to the aorta which is the largest artery.

Aortic Stenosis
Aortic stenosis occurs most commonly as a result of acute rheumatic fever. Congenital or degenerative causes may also cause aortic stenosis.

The most common congenital cause is a bicuspid aortic valve, although it is supposed to be tricuspid. The valve attempts to overcome the obstruction in front of it by increasing the muscle mass (hypertrophy) of the left ventricle, which pumps blood to the body. Over time, the compensatory mechanism becomes inadequate and heart failure results. Patients usually live a long time without symptoms. The valve area is usually 2.5-3.5 cm2, and symptoms occur when this area falls below 1cm2.

The classic symptoms of aortic stenosis are:
congestive heart failure (dyspnea, fatigue, peripheral edema), chest pain, and syncope (fainting). After the appearance of these symptoms, the course of the disease worsens. Although an echocardiogram is sufficient for diagnosis, cardiac catheterization should be performed for preoperative assessment.
In an echocardiogram,
A valve area of less than 0.7 cm in asymptomatic patients or in patients with congestive heart failure, angina (chest pain), and syncope is sufficient to indicate surgery. If the average systolic pressure difference between the left ventricle and the aorta exceeds 50 mmHg, this is an indication for surgery.

Aortic Valve Regurgitation

The most common cause of aortic valve regurgitation is acute injury from rheumatic fever. In addition, disease and trauma to the connective tissue holding the valve can also cause valve regurgitation. In aortic valve regurgitation, some of the blood pumped into the aorta flows back into the left ventricle, resulting in an increased workload on the ventricle. Just as in stenosis, this condition is tolerated for a time by hypertrophy of muscle mass. However, over time, the function of the ventricles deteriorates. It takes many years for symptoms to appear. The first symptom is dyspnea due to left ventricular dysfunction. Over time, heart failure and angina (chest pain) occur.

Asymptomatic patients with normal left ventricular function should be treated medically and followed up. In asymptomatic patients, if left ventricular function deteriorates on echocardiogram (if there is a decrease in FS and EF with a left ventricular end-systolic diameter greater than 55 mm), catheterization should be arranged, and if severe aortic regurgitation and left ventricular dysfunction are found on catheterization, the patient should undergo surgery.

Patients with severe aortic regurgitation and congestive heart failure should be operated on as soon as possible.

Surgical treatment

Surgical treatment consists of replacing the heart valve with a prosthetic valve of appropriate size and structure. In some cases, the aorta (the main artery of the heart) is enlarged, and the valve is inadequate at the same time. In this case, it may be necessary to replace the aorta together with the valve with an artificial material in the form of a tube called a graft.