Beyond AS: Mitral Valve Disease

Patricia Brown Glover

 

Mitral and tricuspid valve disease are more common than aortic stenosis but can be more challenging to address.

By Rachel Hedstrom

Patricia Brown-Glover had climbed mountains before. An educator by trade and a driven mother of two sons, she had already waged and won a battle with cancer. But every day feels like another uphill battle to her.

“The older I get, the more tired I become. I feel like my opportunities were robbed,” says Brown-Glover, who used to count doing yard work and playing basketball with her sons as some of her favorite activities.

The culprit? Mitral valve disease, a condition more common than aortic stenosis, but often more challenging to address (and less talked about). For Brown Glover and thousands of other Americans, this heart valve disease limits their ability to keep climbing.

Understanding Valvular Disease

Valvular disease describes a host of cardiac diseases that affect the heart valves.

People with valvular disease live with such symptoms as dizziness, fatigue, shortness of breath and abnormal heart rhythms. When left untreated, its complications can result in death.

Diseases of the heart valves become increasingly common with age. According to a study published in the Lancet in 2006, between the ages of 18 and 44, less than 1% of the U.S. population had heart valve disease. This increased to 8.5% between ages 65 and 74, and 13.2% after age 75. It’s estimated that approximately 5 million people in the U.S. have a disease of their heart valves today, but that number could be as high as 8.7 million to 11.6 million, according to the Alliance for Aging Research.

“A lot of diseases go unrecognized for a long time, but it’s because a lot of them are not thought to be as severe as they are,” says Firas Zahr, M.D., an assistant professor of cardiovascular medicine in the OHSU School of Medicine in Portland, Oregon, and co-director the OHSU Knight Cardiovascular Institute’s Complex Heart Valve Program.

Many people show symptoms when they are exercising or doing daily activities (like the activities that now cause Brown-Glover to feel worn out), but not when they are at rest, making this disease challenging to diagnose, Dr. Zahr says.

What Is Non-aortic Valvular Disease?

The aortic valve, which controls blood flow from the left lower chamber (ventricle) in the heart to the aorta (blood vessel that carries oxygenated blood from the heart out to the body), is often responsible for death from valvular disease. The Centers for Disease Control and Prevention reports it as the culprit in 61% of all valvular heart disease-related deaths. Aortic stenosis, a narrowing of the aortic valve opening, is one of the most common and serious valve disease problems, and because of that, it gets a lot of attention.

In mitral valve disease, the mitral valve, which is located between the left heart chambers (left atrium and left ventricle), doesn’t work properly. This means oxygenated blood can’t flow well to the left ventricle to be pumped out to the body.

Mitral stenosis is a disease of the mitral valve where the valve is narrowed and therefore can’t move blood well from the left atrium to the left ventricle. As a result, the volume of blood bringing oxygen from the lungs is reduced.

In mitral valve regurgitation, the flaps, or leaflets, of the mitral valve don’t close tightly, causing blood to leak backward into the left atrium of the heart. If not treated, it can result in heart muscle damage. People with mitral valve prolapse have leaflets that bulge back into the left atrium as their heart contracts.

Mitral valve disease makes up 15% of valvular heart disease deaths, while diseases of other valves (the tricuspid and pulmonary valves) together make up another 24%. The number of people affected is smaller than the number battling aortic stenosis, but these non-aortic valvular diseases are gaining more attention, thanks to an increasing variety of treatments. And, since many of those treatments don’t require surgery, they’re changing the conversation around non-aortic valve disease.

Having a Heart-to-Heart

As with most medical challenges, communication with your doctor is key because getting an accurate diagnosis is the first step toward treating and managing the condition. The acronym “LISTEN” may help you know if you have symptoms of a valvular disease:

  • Lightheaded, faint or dizzy feelings
  • Irregular heartbeat, heart flutter or chest pains
  • Shortness of breath after light activity or even while lying down
  • Tiredness, even if you’ve had plenty of sleep
  • Edema, or swelling
  • Not feeling like yourself, or missing out on daily activities

The symptoms can be easy to miss. But for Brown-Glover, a move from Virginia to North Carolina made her more active — and made it hard for her to ignore her symptoms. “I’m a very meticulous person and I was organizing everything in the house and the attic for my move,” she says. “I was thinking maybe I had asthma,” she says of her inability to breathe normally.

She didn’t suspect heart disease, as it wasn’t in her medical history. Doctors said her mitral valve disease could have been a side effect of the chemotherapy she took to treat the acute promyelocytic leukemia she was diagnosed with at age 39. “The data is out now to show that any type of chemo treatment can cause heart failure,” says Brown-Glover, now 60. “I know that and I have to move on.”

More Options for Treatment

As the population ages, doctors are seeing more mitral and tricuspid valve disease, Dr. Zahr says. While age increases the chances for valvular diseases, it also prohibited treatment in years past, as doctors didn’t recommend surgery for older patients with valvular disease.

While open-heart procedures are still necessary for some patients, minimally invasive treatment options, like procedures done during a cardiac catheterization instead of surgery, are also now available. “Today, many older or frail patients can go home the day after having a transcatheter heart valve procedure,” Dr. Zahr says. “These options make treatment possible for many more people.”

Devices like mechanical valves and mitral clips continue getting smaller and more delicate, and the non-surgical approach used to place them often means less pain, smaller incisions and less overall wear and tear on the body than traditional open-heart surgery.

In a transcatheter procedure, for example, a doctor makes a small incision to place a catheter (long, thin tube) into a patient’s artery usually through their groin. The doctor then places a device, or new valve, into the patient’s heart through that catheter. “This approach requires less anesthesia than open-heart surgery, and there is no need for a heart/ lung bypass machine,” says Dr. Zahr.

“It’s rare to find a patient who can’t be helped by one of today’s many treatment options. As the therapy is becoming less invasive, people who are not candidates for traditional options, like surgery, are coming to us for minimally invasive transcatheter options.”

Other minimally invasive procedures also are being evaluated in clinical trials as options for treatment. “[At OHSU], we have six or seven clinical trials that make repair available for patients. The difficulty is in trying to figure out which one of those options is the best,” Dr. Zahr says. A multi-disciplinary team at OHSU reviews every case in a weekly meeting to discuss which repair might be best for each patient.

Support for Minimally Invasive Treatments

In 2020, the American Heart Association and the American College of Cardiology announced new guidelines to advise healthcare providers on treatments for valvular disease. They call for using less invasive treatment options except in the most severe cases.

Stenosis can now be treated with valve replacement using a catheter instead of open-heart surgery. There also are less risky and longer-lasting treatments for repairing or replacing the “leaky” valves involved in regurgitation.

Practicing healthy habits is also an important part of treatment and management, Dr. Zahr says. Eating well, limiting salt intake, getting proper activity and learning to listen to your body are some of his recommendations for patients with mitral valve disease. He also recommends that patients get a referral to a center of excellence in valvular repair and replacement; centers with good outcomes also tend to have a wider variety of clinical trial options available for patients.

Living With Mitral Valve Disease

Brown-Glover had a mitral valve repair in 2007 and a mitral valve replacement in 2019, as well as multiple surgeries for her pacemaker. She recommends that any person diagnosed with mitral valve disease keep careful records, tell their story and continue to set goals for themselves.

“Every time I have a chance to tell my story, I do,” she said. She recently wrote a book and is planning workshops to help others through their own challenges. Her No. 1 piece of advice?

“Build your village. That’s what’s going to get you through this,” she says. “Document and take notes so that on the other end of it, you can be appreciative because you know where you came from — the days you couldn’t breathe, this that or the other. Become a member of Mended Hearts® and the American Heart Association so you get professional data and information.”