Aortic Valve Disease

Original Editor - Lucinda hampton

Top Contributors - Lucinda hampton  

Introduction[edit | edit source]

AorticValve RegurgitationvsStenosis.png

Aortic valve disease can be caused by aortic stenosis, aortic regurgitation, or a combination of both. [1] The pathology may develop over many years, symptoms may not appear until the condition is severe; at this point, the morbidity and mortality of aortic valvular disease are very high[2].

  1. Aortic valve stenosis is the most common valvulopathy and describes narrowing of the opening of the aortic valve between the aorta and the left ventricle[3].
  2. Aortic valve regurgitation, also known as aortic valve insufficiency or aortic valve incompetence, is a valvulopathy that describes leaking of the aortic valve during diastole that causes blood to flow in the reverse direction from the aorta and into the left ventricle[4].

Image 1: Aortic Valve Regurgitation vs. Aortic Valve Stenosis

Structure and Function of the Aortic Valve[edit | edit source]

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Cardiac valves are structures that are designed to work like one-way doors. They let blood flow in from one chamber or vessel to another, and then close to prevent the blood from regurgitating backward. The aortic valve consists of 3 half-moon-shaped pocket-like flaps of delicate tissue, referred to as cusps. When the aortic valve is closed, the cusps are perfectly aligned and separate the large pumping chamber of the heart (the left ventricle) from the large artery (aorta) that supplies blood to the body. During the period when the left ventricle contracts and pumps the blood (systole), the aortic valve opens widely and blood flows freely from the left ventricle to the aorta. When the left ventricle then relaxes (diastole), the aortic valve closes completely so that the blood remains in the aorta. During diastole, blood flows into the left ventricle from the lungs through the left atrium across the mitral valve, thus refilling the ventricle for the next contraction[1].

Etiology[edit | edit source]

There are two common causes of aortic stenosis (AS), calcified (age-related) aortic stenosis and congenital bicuspid aortic valves. Rarely aortic stenosis and/or aortic regurgitation can be a result of rheumatic heart disease.

  • Calcified aortic stenosis is by far the most common etiology and is believed to occur via progressive endothelial damage over many years.
  • Causes of chronic aortic regurgitation include include the same pathologies that most commonly cause aortic stenosis.[2]

Epidemiology[edit | edit source]

Aortic valves.jpeg

Aortic stenosis

  • The most common valvulopathy. The condition has a male predilection in a 4:1 ratio, and the incidence of degenerative aortic valve disease, the most common aetiology of aortic stenosis, is increasing.[3]
  • More prevalent in the elderly population (fifth through eighth decades). According to a prospective population-based study, the incidence of aortic stenosis was 0.2% during the fifth decade of life, 1.3% during the sixth, 3.9% during the seventh, and 9.8% during the eighth[2].

Aortic regurgitation

  • Occurs slightly more in males, and the incidence increases progressively after the age of 50 years.[4]
  • Estimated prevalence of 4.9%, increasing with age until the sixth decade when incidence begins to decrease. [2]

Signs and Symptoms[edit | edit source]

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The main sign of heart valve disease is an unusual heartbeat ie Heart murmur . Heart valve disease often worsens over time, so signs and symptoms may occur years after a heart murmur is first heard. Many people who have heart valve disease don't have any symptoms until they're middle-aged or older.[5]

Chronic aortic regurgitation and late in disease progression of aortic stenosis symptoms generally fall into two categories; heart failure and decreased coronary and systemic perfusion. Overtime increased pressures in the left ventricle lead to congestive heart failure; patients may complain of pedal edema, shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and exertional dyspnea. Patients may state that they require additional pillows at night to sleep because lying flat causes them to be short of breath. Additionally, patients may complain that they have decreased exercise tolerance, the number of city blocks they can walk before feeling short of breath or lightheaded decreasing. In severe disease states, patients may present with syncope or may also complain of anginal symptoms[2]

Treatment[edit | edit source]

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There is no medical management that can delay the progression of asymptomatic aortic valve disease. Management is a two-prong approach focusing on optimizing other cardiac comorbidities (eg hypertension, coronary artery disease, left ventricular dysfunction, atrial fibrillation) and vigilante serial evaluation to monitor for disease progression and early detection of symptoms.

  • Caring for patients with aortic valve disease requires an interprofessional team approach, including clinicians/specialists, mid-level practitioners (NPs and PAs), specialty-trained nurses, and pharmacists, all collaborating across disciplines to achieve optimal patient results[2].
  • Lifestyle changes and medicines often can treat symptoms successfully and delay problems for many years. Eventually, though, surgery may be needed to repair or replace a faulty heart valve.

The goals of treating heart valve disease may include:

  1. Medicines
  2. Repairing or replacing faulty valves.
  3. Heart-healthy lifestyle changes to treat other related heart conditions

Valve Surgery[edit | edit source]

Mechanical heart valves.jpeg

The decision to repair or replace heart valves depends on many factors, including:

  • The severity of valve disease
  • Whether client needs heart surgery for other conditions, such as bypass surgery to treat coronary heart disease. Bypass surgery and valve surgery can be performed at the same time.
  • Age and general health

When possible, heart valve repair is preferred over heart valve replacement. Valve repair preserves the strength and function of the heart muscle. People who have valve repair also have a lower risk of infective endocarditis after the surgery, and they don’t need to take blood-thinning medicines for the rest of their lives.

However, heart valve repair surgery is harder to do than valve replacement. Aortic valves often have to be replaced[5].

Prognosis[edit | edit source]

Prognosis is largely determined by the time of onset of symptoms. Asymptomatic patients who do not progress to symptomatic have a longer life expectancy. Prognosis of patients with severe symptomatic aortic valve disease who do not undergo valve replacement is very poor, with survival at 3 years ranging from approximately 40 to 60%, whereas those who underwent valve replacement ranged from 80 to 90%[2].

Complications[edit | edit source]

Congestive heart failure; Sudden cardiac death from arrhythmia; Calcified cerebral embolism; Heyde syndrome[3]

Physiotherapy[edit | edit source]

Strengthing exercise for old people .jpg

A multidisciplinary rehabilitation program should therefore be available for all patients undergoing valve surgery to initiate an exercise program while in the hospital.Rehabilitation professionals working in acute care need to consult with other members of the medical team to fully explore the risk versus benefits of physical therapy intervention, to assist with the development of facility policies, procedures, and/or protocols for clinical decision making to determine the aggressiveness of physical therapy intervention acutely following surgery.

Outcome Measures:

  • It is integral for the physical therapist to complete a comprehensive examination whenever possible using the most appropriate tests and measures. eg The 30-second chair rise , FIM scores, 10MWT [6]

Following discharge Cardiac Rehabilitation is preferable. See link.

References[edit | edit source]

  1. 1.0 1.1 Nishimura RA. Aortic valve disease. Circulation. 2002 Aug 13;106(7):770-2.Available from: https://www.ahajournals.org/doi/full/10.1161/01.cir.0000027621.26167.5e(accessed 21.5.2021)
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Wenn P, Zeltser R. Aortic Valve Disease. StatPearls [Internet]. 2020 Mar 24.Available: https://www.ncbi.nlm.nih.gov/books/NBK542205/(accessed 21.5.2021)
  3. 3.0 3.1 3.2 Radiopedia AV stenosis Available from: https://radiopaedia.org/articles/aortic-valve-stenosis?lang=gb (accessed 21.5.2021)
  4. 4.0 4.1 Radiopedia AV regurgitation Available from: https://radiopaedia.org/articles/aortic-valve-regurgitation?lang=gb(accessed 21.5.2021)
  5. 5.0 5.1 NIH heart valve disease Available: https://www.nhlbi.nih.gov/health-topics/heart-valve-disease (accessed 21.5.2021)
  6. Fernandez N, Blackwood J. Acute care physical therapy management of a 69-year-old female following re-operative aortic valve replacement and tricuspid valve repair: A case report.Available from:https://www.oatext.com/acute-care-physical-therapy-management-of-a-69-year-old-female-following-re-operative-aortic-valve-replacement-and-tricuspid-valve-repair-a-case-report.php (accessed 21.5.2021)