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Diseases of Heart Valves

INTRODUCTION

Heart failure is a condition that occurs when the heart cannot pump or fill with enough blood, which means that the heart must work harder to deliver blood to the body. The term “heart failure” is misleading because the heart does not completely fail or stop. Heart failure can be mild and cause minor symptoms, or it may be severe or even life-threatening. The most common symptoms of heart failure are shortness of breath, feeling tired, leg swelling, and other signs of fluid retention.

Although heart failure is a serious condition, safe and effective treatments are available. Treatment can help you to feel better and live longer.

TYPES OF HEART FAILURE

The heart is composed of four chambers: The two upper chambers are the right and left atria, and the two lower chambers are the right and left ventricles (figure 1). The left ventricle plays a key role because it pumps blood to the entire body. In a person with heart failure, the heart cannot adjust to the body’s changing need for oxygenated blood (for example, when climbing stairs).

There are two main types of heart failure. They are defined based on whether the “ejection fraction” (which indicates how well the left ventricle is able to pump) is preserved or reduced:

  • In ”heart failure with reduced ejection fraction” (also called “HFrEF” or “systolic heart failure”), the heart is too weak. When the heart pumps, it doesn’t squeeze normally.
  • In ”heart failure with preserved ejection fraction” (also called “HFpEF” or “diastolic heart failure”), the heart is too stiff. When the heart pumps, it doesn’t relax and fill with blood normally.

HEART FAILURE CAUSES

Heart failure is caused by a disease or condition that damages the heart. Fortunately, treating these conditions during the early stages can often prevent or slow development of heart failure. The most common causes of heart failure include:

High blood pressure (hypertension) — In people with high blood pressure, the heart must work harder to pump blood. This increased workload can, over time, lead to an enlarged heart that does not work well.

Coronary heart disease — Coronary heart disease causes narrowing of the blood vessels that supply (“feed”) the heart muscle, reducing the flow of blood through the vessels. As a result, portions of the heart muscle are deprived of oxygen (especially during exercise, when the body needs more blood supply and oxygen), and the heart does not perform its work as well. Coronary heart disease can also lead to a heart attack (also called a myocardial infarction), which causes permanent damage to the heart muscle. Coronary heart disease can cause heart failure when it impairs the function of the heart.

Heart valve disease — A number of conditions, including heart attack and aging, can damage the heart valves.

  • The valve can become narrowed (stenosed), which interferes with blood flow through the valve and increases pressure in the heart.
  • In other cases, the valve can become leaky (insufficient), causing blood to flow backward (regurgitation).

Cardiomyopathy — In cardiomyopathy, the structure and/or function of the heart muscle is altered, leading to a poorly pumping heart that may exhibit either HFrEF or HFpEF.

HEART FAILURE SYMPTOMS

As the amount of blood pumped by the heart (the cardiac output) decreases, a variety of symptoms can develop.

  • Weakness, particularly of the legs when exercising.
  • Lightheadedness or dizziness.
  • Shortness of breath, which might require you to be less active or sleep with several pillows to elevate your head.
  • A rapid heart rate, even while resting.
  • Swelling in the lower legs and feet (edema) or in the abdomen (ascites).
  • Feeling tired or fatigued quickly.

HEART FAILURE TREATMENT

In most people, heart failure is a chronic problem, meaning that it continues for months and years. Heart failure is generally treatable but rarely goes away completely. Treatment usually includes a combination of changes in your diet and lifestyle, medicines, and sometimes a device to protect your heart from abnormal rhythms.

Diet and lifestyle — Changes in diet and lifestyle are often recommended to treat heart failure. The most common recommendations include:

Decrease salt and water – Salt in the diet can cause the retention of excess fluid in the circulation, lungs, and elsewhere in the body. Therefore, managing the amount of salt (sodium) in the foods you eat can help to keep heart failure under control.

The amount of fluid you drink is also important. People with severe heart failure should drink less than 2 liters (66 ounces) of fluid per day. This includes all fluids.

Weigh yourself every day – To monitor your fluid levels, weigh yourself every day at the same time on the same scale (eg, in the morning after you urinate but before eating breakfast). Be sure to wear the same amount of clothing each time you weigh yourself. If your weight increases by 2 pounds (1 kilogram) in one day, call your doctor or nurse. Also, if your weight increases by four pounds (2 kg) in one week, call your doctor or nurse. Gaining weight suddenly is one sign that you may be retaining more fluid than you should be.

Control your weight – If you are overweight, your heart must work harder to supply blood and oxygen to your body. Losing weight can help you to feel better and reduces the strain on your heart

Stop smoking and Limit alcohol – Drinking too much alcohol is not good for your heart or your health generally. People with heart failure should not drink more than one serving of alcohol per day (for women) or two servings per day (for men). One serving is 12 ounces of beer or 5 ounces of wine.

Cardiac rehab and exercise – Exercising most days of the week can help to improve the fitness of your cardiovascular system and exercising muscles, and thereby reduce shortness of breath and fatigue, which are common problems in people with heart failure.

ICD/CRT-D Implant — In some people with heart failure, an abnormal heart rhythm develops. Some abnormal heart rhythms are treated with medications.

If you have a condition that causes an abnormal heart rhythm, your doctor might recommend a device that shocks the heart and returns it to a normal rhythm. The device is called an implantable cardioverter-defibrillator (ICD). It is implanted under the skin in your upper chest.

Another potential problem in people with heart failure is abnormal electrical conduction in the heart. This can cause the walls of the left ventricle to contract out of sync, making the heart work less efficiently. A special type of pacemaker, called cardiac resynchronization therapy (CRT) or biventricular pacing, can treat this problem. A device that includes both CRT and ICD is available (CRT-D).

Surgery or stenting — Surgery or angioplasty and stenting is sometimes recommended for people with heart failure who also have coronary heart disease or severe disease of the heart valves.

Treatment for advanced heart failure — Heart transplantation can be helpful for some people with severe heart failure that has not responded to other treatments. However, careful screening is required to ensure that heart transplantation is appropriate. In addition, the supply of hearts for transplant is limited, so most people must wait for months or even years before a heart is available.

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Figure – Drawing of ICD implant

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Figure – Drawing of CRT-D implant

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