Valve Disease — It Often Starts With a Murmur

Heart valve disease affects more than five million Americans each year. It occurs when one or more of the heart’s four valves aren’t working the way they should. In a normal anatomy, the heart’s valves open and close every time your heart beats to control blood flow. But, when they aren’t working properly, the heart can’t do its job – which is to pump blood efficiently through the body. 

Because heart murmurs occur when blood flows abnormally through the heart, a murmur is often one of the first signs of valve disease. Murmurs are unusual sounds – often denoted as a whooshing, swishing, humming or rasping sound that a doctor can hear during a routine medical exam using a stethoscope. While many murmurs are harmless – also known as “innocent” heart murmurs – some are classified as “abnormal,” and can indicate a defect in the structure of the heart valve, or other heart valve abnormality. Narrowing and hardening of the heart valves can also lead to a heart murmur, which is more common as we age.

Classifying & Evaluating Heart Murmurs

If your doctor identifies a heart murmur, it’s important to get it checked out by a cardiologist. They will talk to you about your medical history and perform a physical/clinical exam to learn more. Murmurs are evaluated for volume, location (where it’s coming from), frequency (sound or pitch), and duration (how long it lasts). In many cases, patients with a murmur will be referred for an echocardiogram. This test provides detailed images of the heart valves, chambers, structure and how it’s functioning – all in an effort to identify what is causing the murmur and how serious it is. Murmurs can broadly be grouped into two categories:

• Systolic murmurs occur during heart muscle contraction and sound like a ‘swishing’ sound. Some are ejection murmurs, caused by blood flowing through a narrowed vessel or abnormal valve, while others are regurgitant murmurs caused by blood flowing backward into one of the heart’s chambers.
• Diastolic murmurs occur when the heart muscle is at rest between beats and are identified as a ‘whooshing’ sound. These murmurs occur when the mitral or tricuspid valve is narrowed or when there is regurgitation (backward blood flow) from the aortic or pulmonary valves.

“When evaluating a patient for a heart murmur, we want to identify what’s causing it,” explains Dr. Andrew Sampson, WakeMed Heart & Vascular - Structural Heart. “This helps us determine how to best treat the underlying problem – which in many cases may be a leaky or damaged valve.”

Dr. Sampson explains that the three most common valve problems he sees that may result in a heart murmur include mitral regurgitation, aortic stenosis and severe tricuspid regurgitation. He explains these three structural heart problems in detail.

Mitral regurgitation (also known as a leaky valve, mitral valve regurgitation or mitral valve insufficiency) is one of the most common types of heart valve disease. The heart murmur it causes is systolic and makes a ‘whooshing’ sound. Caused by the flaps of the mitral valve that don’t close properly, the result is backward flowing blood into the heart. This backward flow means not enough blood moves forward for the body to function as it should. The heart must work harder to overcome the lack of blood flow, which can lead to heart failure, arrhythmia, blood clots and stroke. In many cases, mitral regurgitation occurs slowly over time and patients may not notice until their symptoms, including fatigue, shortness of breath, heart palpitations and swelling of the hands and feet, become life-limiting.

Aortic stenosis (AS) is another common heart valve problem caused by narrowing of the aortic valve opening. It leads to a systolic, high-pitched murmur that is heard when the blood is trying to move through a smaller opening due to a stiffened or narrowed aortic valve. Heart defects, such as a bicuspid aortic valve, are causes, but AS also occurs frequently during aging when scarring or calcium deposits damage the valve and restrict blood flow.

According to the American Heart Association, more than 13 percent of Americans over the age of 75 have aortic stenosis. If left untreated, aortic stenosis can lead to heart failure. Symptoms of AS may include chest pain, rapid heartbeat, trouble breathing or shortness of breath, dizziness, or a decline in regular activity – although these symptoms generally occur long after the disease begins.

Tricuspid regurgitation (TR) occurs when the valve that connects the upper and lower chambers on the right side of the heart doesn’t close properly – leading to backward blood flow. When the tricuspid valve is leaky, a murmur that is systolic makes a ‘whooshing’ sound that may be heard during a physical exam. However, as the regurgitation progresses, the murmur may be harder to hear. If left untreated, TR can lead to atrial fibrillation and/or heart failure. Like most heart valve problems, TR often doesn’t cause symptoms until the disease has progressed significantly. Symptoms of advanced disease include extreme fatigue, shortness of breath, rapid heart-beat, pulsing feeling in the neck, or swelling in the belly, legs or neck veins.

Treating Heart Valve Disease

In early stages, most heart valve diseases are first treated with medications and managed by a cardiologist who will continue to monitor the progression of the condition. As symptoms become more severe and quality of life is affected, patients should consider consulting a structural heart specialist or a cardiovascular surgeon to explore other options.

“We’re fortunate that significant advancements in the field continue to allow us to better treat structural heart problems like valve disease,” explains Dr. Sampson. “There are many options we didn’t have available just five years ago, and there are more exciting advancements on the horizon that can really help improve symptoms and quality of life for our patients.”

Common procedures performed at WakeMed Heart & Vascular include TAVR, a heart valve replacement
procedure, or valve repair procedures like the MitraClip. We also perform procedures to correct septal defects that can contribute to stroke or valve disease.

“It’s exciting to be part of a field that continues to evolve. In addition to all the options we have today, there are new medications, novel minimally-invasive procedures and methodologies, as well as new devices all in development for the treatment of advanced valve disease,” Dr. Sampson says. “For patients who have valve disease affecting their quality of life – it’s never too late to seek treatment. There may be treatments you haven’t been offered in the past that can help you live a longer, fuller life.”

This blog is adapted from WakeMed's Heart to Heart Magazine. Subscribe today.