Central  South  Dakota Medical News
The Clinical View
by P.E. Hoffsten, M.D.

WHEN TO FIX A HEART VALVE

     Of the many structures in the human body, the four valves in the heart are certainly among the most durable and long lasting.  If one calculates that a heart beats an average of 100,000 times per day for 365 days each year and the average age of people in the United States now  is approaching  80 years, the average human heart beats almost three billion times in a life time. Those tiny delicate heart valves have to open and close one or more times per second three billion times without breaking.  No manmade structure even begins to approach that kind of durability.

      Of the many things that can go wrong with a human heart, malfunction of these valves is relatively unusual.  The arteries of the heart can get stopped up and cause heart attacks resulting in six hundred thousand deaths per year in the United States.  That is one third of all of the deaths that occur.  The heart muscle itself can fatigue and cause heart failure.  This is one of the most expensive medical conditions in our society affecting about 5% of the population.  Yet it is relatively rare that the valves of the heart malfunction.

       If you think about it, there is really only two things that can go wrong with the valve. The valve can get stopped up or it can leak and both of these problems do occur in human hearts. If a valve leaks, the condition is called  “insufficiency”.  There is a valve between the heart and the lungs called the mitral valve.  This one keeps blood from going back into the lungs when the heart pumps and thus, the blood goes forward out to the body where it belongs.  If the mitral valve becomes insufficient, part of the blood that came from the lungs into the heart gets pumped back into the lungs which is both a wasted effort and hard on the lungs.  Mitral insufficiency is the most common leaky valve problem doctors encounter.

       If a valve becomes stopped up, the condition is called “stenosis”.  The most common stenosis problem patients encounter involves a valve called the aortic valve.  This valve is between the heart and the body.  If this valve gets stopped up, the heart has to pump much, much harder to get the blood out through that little tiny hole that was the aortic valve.  To the heart, this looks as if the body is laboring under high blood pressure and wears the heart out.

       Thus, the two most common valves that need to be fixed are the mitral valve when it is leaking and the aortic valve when it is stopped up.  When these valves malfunction, eventually the heart will fail and the person develops all of the symptoms called “congestive heart failure”. These include easy fatigue, shortness of breath with any exertion, swelling of the ankles, and getting up to pass urine three to five times per night.  In extreme cases, the person can become wheelchair bound because they are too fatigued to walk.

       Fortunately, when a valve malfunctions, modern surgical techniques can replace the valve and restore the hearts function remarkably well.  For mitral insufficiency, the best result of valve replacement occurs when the valve is fixed just as the heart is beginning to fail.  Once the valve malfunction is diagnosed, the person can be followed in the clinic and discussion on heart valve replacement made based upon certain measurements.

       For aortic stenosis, the best result of heart valve replacement comes with replacement when the open area of the valve reaches a certain small critical value beyond which the heart fails relatively quickly.  Three important warning signs for people with aortic stenosis are chest pain, fainting spells, and worsening heart failure.  Sudden death can occur unexpectedly when anyone of these three symptoms might occur in a person with aortic stenosis.

       As you might expect, heart valve malfunction tends to occur in the elderly population. Many times I hear a person say that they are too old to fix their heart or that they “couldn’t stand the surgery”.  The real answer is that if  surgery is suggested, the person can’t stand the disease very much longer.  Recently an article was published in the American Journal of Medicine that discussed heart valve surgery done in 100 consecutive people at the Cleveland Clinic.  The distinguishing feature of these people was that each of them was more than 80 years old and fourteen of them were older than 90 years old.  The authors published the article to point out that not even one person had a mortal outcome from the surgery.  Heart surgery can be done safely and effectively in individuals more than 80 years of age.

       I am an advocate of quality of life.  I would like for whatever years a person has on this earth to be comfortable ones where a person can do what they enjoy.  When a heart valve problem robs an individual of their ability to do the activities that they enjoy, its not crazy to go have the heart valve fixed. As the article above points out, it’s a remarkably safe procedure even for those individuals 80 years of age and older.

       The healthcare providers at your local clinic can help diagnose valve problems and help make decisions and advise you when a heart valve problem occurs.