Diseases of the heart valves
The heart has four valves that separate the atrium from the ventricle (mitral valve and tricuspid valve) and the ventricle from the downstream blood vessel (aortic valve and pulmonary valve) (Fig. 1). Like a valve, the heart valves ensure that the blood is pumped in the right direction and that the heart can work effectively.
The heart valves can be narrowed (stenosis) or no longer close properly (insufficiency) due to genetic predisposition or in the course of life. In the event of an acute bacterial infection in the body, germs can also adhere to the surface of the valve and cause dangerous changes.
How are heart valve defects and heart failure related?
If one of the valves no longer closes properly in the long term, this puts a lot of strain on the heart, as blood keeps flowing back and the heart's pumping capacity decreases. It has to work harder to transport the same amount of blood. This constant strain can lead to heart failure. People who already suffer from heart failure can also have heart valve insufficiency, which then exacerbates the symptoms of the existing heart failure.
Stenosis, i.e. the narrowing of a heart valve, often due to calcification, can also cause heart failure because only a small amount of blood can pass through the opening with each heartbeat.
Therapy of heart valve diseases
There are various options for treating diseases of the heart valves, such as the aortic valve, mitral valve and tricuspid valve. For example, your doctor can prescribe medication to support heart activity and slow down the negative consequences of the disease. These include ACE inhibitors, beta-blockers and diuretics. Surgery is the method of choice for many heart valve diseases. In a surgical procedure, the defective valve is either repaired or replaced with an implant.
Percutaneous valve therapy
Another option for treating defective heart valves is the newer, so-called percutaneous valve therapy. Percutaneous means "through the skin" and indicates that these are procedures that do not require surgery and are therefore also an alternative for patients for whom general anesthesia is not an option. This may be the case, for example, if anesthesia is too dangerous due to severe circulatory stress or other pre-existing conditions. Well-known minimally invasive valve procedures include transcatheter aortic valve replacement (TAVI), mitral or tricuspid edge-to-edge repair.
TAVI
TAVI stands for the English term "Transcatheter Aortic Valve Implantation", which means the insertion of a new heart valve through the main artery (aorta). This procedure is used for people with severe aortic valve stenosis.
In TAVI, the new heart valve is embedded in a foldable metal scaffold. This is pushed towards the heart using a catheter, e.g. from the groin. There, the new valve is unfolded and can immediately take over the function of the old valve. In this procedure, the old valve is not removed but serves as a support for the new valve; the negative effects of valve stenosis are thus significantly reduced.
TAVI also involves a stay in hospital, but no general anesthetic is required and the treatment is therefore gentler - in contrast to open heart valve surgery. After a TAVI, you can usually leave the clinic after just a few days. Due to the positive results, this procedure is now sometimes also used for patients for whom surgical heart valve replacement is another treatment option after consultation with the heart team, consisting of cardiologists, heart surgeons and anesthetists.
Mitral edge-to-edge repair
This procedure is done while you're asleep under general anaesthesia. A small ultrasound probe is gently passed down your food pipe (oesophagus) to get clear, detailed images of your heart. The poorly closing valve is then stapled together with the clip at the appropriate point (percutaneous mitral valve edge-to-edge repair). This ensures that the blood can continue to flow in the right direction, but the backflow is significantly reduced. As a result, the heart no longer has to work against it and can transport significantly more blood with each beat. As a result of this therapy, the symptoms of mitral regurgitation or heart failure usually improve significantly.
Tricuspid edge-to-edge repair
Under certain conditions, minimally invasive catheter-based repair is also possible for the treatment of tricuspid regurgitation (TR), where the tricuspid valve is leaking and blood can flow back into the right atrium. This procedure is done while you're asleep under general anaesthesia. A small ultrasound probe is gently passed down your food pipe (oesophagus) to get clear, detailed images of your heart. The leaking tricuspid valve is then pulled together and fixed by inserting clip(s) at the appropriate points. This often reduces the leakiness of this heart valve, which can improve the performance and quality of life of many patients.
Finding the right therapy
In order to select the right treatment for each patient, the decision should be made in consultation with the treating physicians. In a "heart team", cardiologists and cardiac surgeons discuss what the optimal therapy is for each person. This includes possible additional illnesses, the age of the patient and the type of valve defect. In principle, percutaneous replacement of all four valves is now possible, but the application is carefully considered in each individual case.
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- References
- 2021 European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS). Vahanian A. et al: Guidelines for the management of valvular heart disease. European Heart Journal (2022) 43, 561-632,
- DGK position paper. Möllmann H. et al: Tricuspid valve regurgitation. Cardiology (2022) 16: 372-382.
- German Society of Cardiology - Cardiovascular Research e.V. (2022). ESC/EACTS Pocket Guidelines. Valvular heart disease, version 2021. Börm Bruckmeier Verlag GmbH, Grünwald.
- Paul Sorajja et al. Transcatheter Repair for Patients with Tricuspid Regurgitation. N Engl J Med 2023; 388(20): 1833-1842.
- German Medical Association (BÄK), National Association of Statutory Health Insurance Physicians (KBV), Association of the Scientific Medical Societies in Germany (AWMF). National Disease Management Guideline Chronic Heart Failure - Long Version. Version 4.0. 2023, at: www.leitlinien.de/herzinsuffizienz (last accessed: April 2024).
- Herzmedizin.de: Herzkrankheiten, at: www.kardiologie.org (last accessed: April 2024).
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