Valve Disease
Valve Disease Overview
The NYU Approach to Valve Disease
Common Valve Disorders
Aortic Valve Disease
Mitral Valve Disease
Research
Our Valve Disease Specialists
Patient Stories
The heart has four valves — mitral, aortic, tricuspid, and pulmonary — that regulate the flow of blood through the heart's four chambers.Each valve consists of flaps, or leaflets, that function like one-way swinging doors. With each heartbeat, the valves open widely to allow blood to flow to the next chamber, and then close tightly to prevent blood from flowing backward.
Valves can malfunction in two ways. One problem is leakage, or regurgitation, in which valves do not completely close, allowing blood to flow in reverse. The second valve disorder is stenosis, or blockage, in which the valve stiffens, limiting how wide it can open and thus how much blood can flow to the next chamber. Either regurgitation or stenosis can significantly limit the heart’s ability to pump blood. Sometimes, a valve can have both problems at once.
The most common valve diseases are aortic stenosis and mitral insufficiency. Triscupid valve disease is rare and usually secondary to other valve disease. Mitral stenosis is usually caused by rheumatic fever, which is unusual in developed countries. Pulmonic valve disease is generally caused by birth defects (congenital) and is usually diagnosed at birth.
Symptoms of valve disease include:
In many cases, valve disease progresses slowly. The heart gradually adjusts (up to a point), so symptoms may go unnoticed for some time. It is important to note that symptoms do not always reflect the severity of valve disease. One may be symptom-free yet have serious valve disease requiring immediate treatment. On the other hand, one may experience frequent symptoms but have a minor valve leakage requiring no treatment at all.
In general, faulty valves create abnormal heart sounds, such as murmurs and clicks, that can be heard with a stethoscope. A more sophisticated, noninvasive test called an echocardiogram is typically used to confirm the diagnosis. Further diagnostic information can be obtained with CT-angiography and cardiac MRI (a noninvasive means of obtaining high-quality cross-sectional images of the heart and the great vessels), both of which are available at a handful of medical centers, including NYU.
Many valve problems — including the majority of cases of mitral valve prolapse — are minor and do not require any treatment. More serious valve disease can be effectively treated through valve repair or replacement. Generally, surgery is required. Recent advances have made it possible to repair or replace valves with minimally invasive procedures, in which the operation is performed without splitting the breast bone. Compared to conventional open-heart surgery, minimally invasive surgery is much less traumatic to the patient. It not only requires smaller incisions, but also leads to fewer blood transfusions, less postoperative pain, shorter hospital stays, and quicker recoveries.
The NYU Approach to Valve DiseaseThe NYU Department Cardiothoracic Surgery is internationally recognized for the treatment of valve disease. Our philosophy of care is to provide the best treatment of valve disease in the least invasive manner.
Translated into practice, that means we believe that it is better to repair, rather than replace, faulty valves whenever possible. Valve repair, which preserves the patient’s own tissue, is a more natural solution than valve replacement. Valve repair is less likely to lead to blood clots, and patients do not have to take blood thinners (a lifelong requirement after mechanical valve replacement). Valve repair is also less likely to lead to infections, is better at preserving heart function, and improves long-term survival.
Our staff is among the world’s most experienced in valve repair surgery, having performed more than 3,000 mitral valve repairs over the last 25 years. We helped refine many aspects of mitral valve repair and were the first to introduce the procedure in the United States.
Unlike most centers, we perform the vast majority of our operations with minimally invasive approaches, with some of the highest success rates and lowest complication rates in the country. Relatively few surgeons are proficient or comfortable with these techniques. However, in the right hands, minimally invasive surgery is far less traumatic than traditional “open” operations and, in certain patients, dramatically improves survival rates (especially among high-risk seniors undergoing aortic valve replacement surgery, as our research has demonstrated).
Our surgeons have more experience with minimally invasive valve surgery than any other medical center in the nation. The world’s first minimally invasive mitral valve repair was performed here at NYU in 1996. Since then, we have performed thousands of minimally invasive valve surgeries. Our staff is regularly invited to lecture on advances in cardiothoracic surgery around the world and has trained more than 350 surgeons to perform minimally invasive heart surgery.
Much of our success in repairing and replacing valves can be traced to our close ties with NYU’s expert diagnosticians. These include members of the Noninvasive Echocardiography Laboratory, one of the best facilities of its kind in the nation, and the Cardiac Imaging Section, which uses the latest magnetic resonance imaging (MRI) and computed tomography (CT) technologies to obtain high-quality cross-sectional images of the heart and the great vessels.
To ensure that our patients have access to the latest therapies for valve disease, we maintain an active research program, ranging from basic genetic studies to clinical trials of new techniques and technologies.
Common Valve Disorders Aortic stenosisAortic stenosis is a narrowing of the aortic valve that limits the flow of blood from the left ventricle to the aorta. Over time, this causes the left ventricle to thicken, since it must work harder to pump blood through the narrowed opening. When the heart is stressed, such as during exercise, the overworked ventricle may not get enough blood. This can lead to chest pain, fainting, and even sudden death. In the long term, the ventricle may start to weaken, eventually causing heart failure.
While aortic stenosis may occur in any age group, most cases of aortic stenosis are seen in people in their 70s or 80s, usually as a result of the natural buildup of calcium in the valve, which gradually increases the valve’s rigidity. A relatively common birth defect called a bicuspid aortic valve, in which there are two leaflets instead of the normal three, can also lead to aortic stenosis. In people with this defect, the valve tends to calcify by the time they reach middle age. Less often, aortic stenosis stems from a case of rheumatic fever during childhood.
Aortic stenosis is readily treatable with valve replacement. There are two types of replacement, mechanical valves and tissue valves. At NYU, the vast majority of valve replacements are done with “third-generation” natural-tissue valves, which have been reengineered in recent years to cause fewer complications and to last longer than previous models. In certain circumstances, it is better for a patient to receive a mechanical valve. Mechanical valves generally do structurally deteriorate, an advantage over natural tissue valves. A major drawback, however, is that the patient must take Coumadin (a blood thinner) for life in order to prevent blood clots.
Most aortic valve replacements at NYU are performed with minimally invasive surgery. The primary advantages are less bleeding, reduced postoperative pain, and shorter recovery times, compared to traditional “open” surgery. Patients generally return to full activities in about three weeks. For older patients, minimally invasive surgery has an additional advantage: a significantly reduced risk of mortality during surgery. Our data, collected on more than 900 patients over age 70, shows that minimally invasive surgery reduces the operative risk in elderly patients by one half, compared to conventional surgical approaches.
Aortic Valve InsufficiencyAortic insufficiency is a condition in which the aortic valve leaflets do not properly close, resulting in leakage back into the heart. With time, this causes the heart to stretch and enlarge, ultimately resulting in heart failure.
Aortic insufficiency is caused by bicuspid aortic valve (a congenital deformity in which the aortic valve has two cusps rather than three), calcification of the aortic valve (as a result of the natural buildup of calcium in the valve, which gradually increases the valve’s rigidity), aortic valve endocarditis (infection of the valve), or connective tissue disorders including Marfan’s disease and Ehlers Danlos syndrome.
Aortic valve replacement should be performed if a patient is either symptomatic from aortic insufficiency, or if the heart begins to enlarge (based on echocardiogram). In most cases, this operation can be performed using minimally invasive approaches.
Mitral Valve RegurgitationIn mitral valve regurgitation, the leaflets of the mitral valve do not close completely, a condition that can allow blood to flow backward (regurgitate) from the left ventricle into the left atrium.
Mitral regurgitation is caused most commonly by mitral prolapse or from damage to the heart muscle induced by a heart attack. Mitral valve prolapse is common, occurring in about 4 percent of men and 7 percent of women. However, only a small portion of people with the condition experience any symptoms. When symptoms do appear, they are usually mild, including an irregular heartbeat, fatigue, lightheadedness, dizziness, difficulty breathing or shortness of breath (especially during exercise), and chest pain.
Most patients with mitral valve prolapse do not need treatment — other than taking antibiotics before undergoing dental work or major or minor surgery, a preventive measure against endocarditis, a bacterial infection of the heart.
People with mitral valve prolapse should have regular checkups to monitor the progression of the disease. Those with signs and symptoms are generally advised to have surgery to repair or replace the leaky valve. At NYU, our approach is to repair the valve before obvious problems emerge, particularly if the patient shows signs of significant valve leakage or heart enlargement (determined by echocardiography). We believe an aggressive approach is warranted because our surgeons can repair most mitral valves, and most of these repairs can be performed minimally invasively. This combination of approaches assures the best long-term outcomes with the least impact on the patient, based on our experience with thousands of patients.
Surgery is also indicated in cases where mitral regurgitation is caused by coronary artery disease and heart attack. Often, this involves mitral valve repair or replacement combined with coronary artery bypass. To determine if this is necessary, coronary angiography is performed preoperatively by our interventional cardiology colleagues.
Other causes of mitral regurgitation include mitral endocarditis (valve infection), rheumatic heart disease, and mitral calcification (the natural buildup of calcium in the valve, which gradually increases the valve’s rigidity). Any of these conditions may require mitral valve operations, if the patient is symptomatic or the heart is enlarged (determined by echocardiography).
Mitral Valve Stenosis
Mitral stenosis is a condition in which the valve has narrowed, decreasing the flow of blood into the left ventricle. This causes the left atrium to enlarge, which in turn may cause palpitations and rapid, irregular heart rhythms (atrial fibrillation). Mitral stenosis also raises blood pressure in the lungs, which may result in heart failure.
Mitral stenosis is primarily caused by rheumatic valve disease, a consequence of rheumatic fever. Rheumatic fever is unusual in people born in the U.S.; most cases are seen among immigrants.
Surgery is indicated in symptomatic patients and in those with enlarging hearts. The majority of these operations can be performed through minimally invasive incisions.
ResearchThe NYU Department of Cardiothoracic Surgery’s tradition of excellence is sustained by an extensive program of basic and clinical research. During the eighties and nineties, members of our staff were involved in the development of minimally invasive heart surgery, mitral valve repair, and minimally invasive mitral valve repair. More recently, two NYU staff members invented a new annuloplasty band, a semi-rigid C-shaped device that is surgically implanted to support the structural integrity of a diseased mitral valve.
Today, our staff is conducting genetic studies of people with mitral valve prolapse in order to learn more about the development of the disease and to devise ways to predict which patients are likely to developing serious complications. In addition, we will soon begin clinical trials of nonsurgical, catheter-based approaches to repairing mitral valve prolapse, and we are working with our colleagues in interventional cardiology to develop advanced “hybrid” operating rooms, combining surgical and interventional technologies.
Our Valve Disease Specialists
Aubrey C. Galloway, MD
Gregory A. Crooke, MD
Alfred T. Culliford, MD
Juan B. Grau, MD
Eugene A. Grossi, MD
David B. Meyer, MD
Greg H. Ribakove, MD
Charles F. Schwartz, MD