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Heart Valve Disease

Where is our heart located?

 Our heart is located inside the rib cage, behind the breastbone (faith board), in a sac
called the pericardium, and on the diaphragm muscle (respiratory muscle). Our heart
can be roughly likened to a cone whose base extends to the right, back and up, and the
top extends to the left, forward and down. The weight of the heart is approximately
220 g in women and 300 g in men.

What is the function of our heart?

 All tissues in our body need oxygen and nutrients to maintain their normal functions.
The transport of these vital substances to the extreme points of our body is through
blood. The main function of the heart, which consists largely of muscle tissue, is to
circulate blood throughout the body. Our heart contracts an average of 70 times a
minute, about 100,000 times a day, pumping about 8 tons of blood into our body every
day. Therefore, it would not be wrong to say that our heart is at the center of our lives.

What is the structure of our heart, how does it pump blood?

 Our heart has a four-cavity structure. It consists of two atria and two ventricles.
Thanks to a wall structure between them, the heart cavities are divided into two as
right and left halves. Atria are the first cavities in which the blood brought by the veins
to the heart is poured. While the right atrium is the cavity where venous blood that has
lost its oxygen from the whole body is poured, the left atrium is the cavity where the
blood that returns to the heart is poured after oxygenation in the lungs. The ventricles
are the main pumping chambers of the heart. The task of the right ventricle is to pump
oxygen-poor blood through a valve (tricuspid valve) to the lungs through the main
pulmonary artery as a result of opening another valve (pulmonary valve). The task of
the left ventricle is to pump the oxygen-rich blood collected in the left atrium after
oxygenation in the lungs again and coming to it through a valve (mitral valve) to the
whole body through the aorta after opening another valve (aortic valve).

What are the main duties of the valves in heart?

 Blood always flows in one direction within the heart, and it achieves this thanks to the
one-way openable valves in the heart. Blood passing through a valve always flows
forward due to the closed lid when it wants to return.

How many valves are there in our heart and where are they located?

 There are four valves in the heart. The aortic valve is located between the left ventricle
and the aorta. The pulmonary valve is located in the initial part of the main pulmonary
artery. The other two valves (tricuspid and mitral valves), also called atrioventricular
valves, are located between the atria and ventricles. Following the filling of the atria
with blood, blood flows through these valves and into the ventricles. Contraction of

the ventricles causes the pressure to increase. Thanks to the increased pressure, the
inlet valves (atrioventricular valves) are closed, preventing the blood from escaping
back to the atria. High ventricular pressure, on the other hand, opens the outlet valves
(aortic and pulmonary artery valves) so that the blood can leave the heart. The right
atrioventricular valve is located between the right atrium and the right ventricle and is
called the tricuspid valve. The left atrioventricular valve is located between the left
atrium and the left ventricle and is called the mitral valve.

What is the structure of the valves in our heart and how do they work?

 The heart valves have thin leaflets called leaflets. The valves ( tricuspid and mitral
valves) between the atria and ventricles of the heart are similar in the way they work.
While there are three leaflets in the tricuspid valve, there are two leaflets in the mitral
valve. These leaflets are firmly attached to a ring-like structure from their base. These
leaflets move away from each other during the passage of blood, bringing the lid to the
open position. During the contraction of the ventricles, they allow the lid to close by
changing the free edges upwards in a kissing manner. Leaflets attach to the muscle
groups (papillary muscles) in the ventricle with rope-like structures (corda tendinae)
emerging from the lower parts of their free ends.

 With the increasing pressure effect during the contraction of the ventricles, the valves
between the atria and ventricles close and the blood is prevented from escaping back
to the atria. This normal working order is achieved in the machine, where all cover and
underside structures function in harmony with each other. Any pathology that disrupts
the work of these valve and subvalvular structures (ring-like structure, leaflets, rope-
like structures and papillary muscles) leads to problems in the valves (mitral and
tricuspid) between the ears and ventricles, preventing the valve from opening and
closing normally.

 In the aortic and pulmonary valves, they are similar in structure (each consisting of
three leaflets) and in the way they work. The aortic valve, located between the left
ventricle and the aorta, opens into the aorta as the pressure in the left ventricle exceeds
the aortic pressure, allowing blood to pass. When the contraction of the left ventricle
ends and begins to relax again, the leaflets of the aortic valve close, preventing the
blood pumped into the aorta from returning to the left ventricle.

The pulmonary valve is located at the beginning of the main pulmonary artery and functions just like the
aortic valve. When the heart is contracting the right ventricle, it opens when the
increased pressure exceeds the pressure of the main pulmonary artery, and when the
right ventricle begins to relax, it closes again, preventing the blood from returning.
As a result of various diseases that prevent these valves from opening and closing
normally, aortic valve and pulmonary valve diseases occur.

What symptoms do heart valve diseases lead to?

 Depending on the severity of the problem in the heart valve (stenosis/insufficiency),
patients may not have any complaints and severe complaints related to heart failure
may occur.

 The most common complaints in patients are fatigue, palpitations (rhythm problems),
shortness of breath, swelling in the legs, and paralysis and similar clinical pictures due
to clotting of various arteries in our body.

Can both stenosis and insufficiency coexist in a heart valve?

 There may be isolated stenosis or insufficiency in the heart valves, and some patients
may have both stenosis and insufficiency together. If the problem that restricts the
opening of a door also restricts the closing of that door, stenosis and insufficiency may

Can heart valve problems be congenital?

 Some of the heart valve diseases are congenital and some are acquired problems.

How is the operation decision made in heart valve problems?
 Surgery decisions in heart valve patients followed by our hospitals are made by the
joint decision of the "Heart Team" members formed by specialist physicians in
different branches. In this board, after evaluating the patients in detail in all aspects,
recommendations are made to the patient about the most appropriate treatment


Where is the aortic valve located and what is its function?

 The aorta is the largest artery in our body and comes out of the left ventricle of our
heart. The aortic valve is located between the left ventricle and the aorta. It normally
consists of three leaflets. As a result of the contraction of the left ventricle, the blood
passing through the leaflets of the aortic valve is pumped forward with great pressure.
When the contraction of the left ventricle ends, the leaflets of the valve close again,
preventing the blood in the aorta from returning.

What does aortic stenosis mean?

 Stenoses in the exit tract of the left ventricle may be below the aortic valve, at the
valve level, or above the valve level. 95% of stenoses in adult patients are located at
the aortic valve level.

 Normally, when the aortic valve is opened, an opening of approximately 3-4 cm2
appears between the leaflets so that blood can pass through. All diseases that prevent
healthy opening of the aortic valve leaflets cause stenosis in the aortic valve. A
significant complaint may not be detected in the majority of patients until the aortic
valve opening is 1 cm2, and if this opening is below 0.7 cm2, there is critical aortic

valve stenosis. In aortic stenosis, the aortic valve area decreases by an average of 0.1-
0.3 cm2 per year.

What causes stenosis in the aortic valve?

 There are two main causes of aortic valve stenosis.
a. Rheumatic Causes:
The cause of30-40% of aortic valve stenosis in developed countries is acute rheumatic fever
sequelae due to childhood tonsil infection. During this period, the affected leaflets stick
together over the years and severe stenosis occurs in the aortic valve due to calcification. This
rate is higher in our country.
b. Non-rheumatic causes:
i. Congenital aortic stenosis:
The most common cause of congenital aortic stenosis is the formation of two leaflets instead
of three of the aortic valve (bicuspid aortic valve). This disease is very common. The
prevalence in the society is 0.9-2%. These patients may lead a normal life throughout their
lives, as well as develop progressive calcification, aortic valve failure, or aortic vascular
diseases. Calcification of the valve usually occurs in the 50-60s
ii. Degenerative (age-related, atherosclerotic type, calcific type of unknown cause)
aortic stenosis:
 There is aortic valve stenosis at an advanced age and severe calcification is present in
the leaflets of the valve. It mostly occurs in the 70-80s.

What happens in aortic valve stenosis?

 As the stenosis in the aortic valve increases, the left ventricle of the heart begins to
contract more strongly to pass the amount of blood the body needs through this
stenosis, and the muscle mass of the left ventricle increases 2-3 times (hypertrophy).
This situation can be likened to a bodybuilder making more muscle by constantly
increasing the weight he/she trains. In this way, the stenosis in the aortic valve may
not show for a long time, but if ECHO control is performed, it can be easily detected
that there is a serious pressure difference between both sides of the stenosis.

What complaints are seen in aortic stenosis?

 If the aortic stenosis is not operated after the complaints occur, the course of the
disease is quite dramatic. The first finding is usually rapid fatigue while exerting

 Due to the increase in muscle mass of the left ventricle, the blood carried by the
coronary arteries begins to be insufficient in these patients (even if there is no

coronary artery disease) and the patient may experience chest pain (if the valve is not
intervened, the average life expectancy is 5 years).
 Due to the stenosis in the aortic valve, fainting may occur during exertion (if the valve
is not intervened, the average life span is 3 years).
 Over time, the relaxation of the left ventricular cavity of the heart begins to
deteriorate. In order to cope with this situation, the left atrium begins to contract more
strongly. Blood supply to the left ventricle becomes largely dependent on the
contraction of the left atrium. A sudden rhythm problem (atrial fibrillation) that may
develop in these patients may stop the contraction of the left atrium and cause severe
heart failure in the patient (if the valve is not intervened, the average life expectancy is
2 years).

Can aortic valve stenosis cause sudden death?

 Aortic valve stenosis is the most fatal valve disease. While the risk of sudden death is
5% in patients without complaints, the risk of sudden death may increase up to 20% in
patients with complaints.


What does aortic insufficiency mean?

 It is the case that blood escapes from the aorta back into the left ventricle during the
relaxation period of the left ventricle as a result of the aortic valve not closing well
enough. The severity is determined according to the amount of blood flowing back to
the left ventricle.

What are the causes of aortic valve failure?

 All conditions that prevent the aortic valve from closing properly cause aortic
insufficiency. The most common cause of aortic insufficiency in developed countries
is rheumatic aortic valve diseases.

The retractions caused by tonsil infections in childhood in the aortic valve leaflets prevent the valve from closing completely.
In addition, damage to the leaflets develops due to infective endocarditis (microbial
infection in the valve) affecting the aortic valve and may cause aortic insufficiency.
The aortic valve is the valve most affected by blunt chest trauma.
Tears and punctures
in the aortic valve leaflets due to trauma may cause aortic insufficiency. Pathologies
affecting the aortic tissue to which the valve is attached (connective tissue diseases
such as Marfan, Ehler-danlos and osteogenesis imperfecta) may also cause
insufficiency in the aortic valve.
This includes aneurysms and dissections that cause enlargement of the aortic root. Aortic insufficiency may occur in patients with congenital bicuspid aortic valve. Aortic failure may also develop in rheumatological
diseases such as syphilis-induced aortic involvement, rheumatoid arthritis and SLE,
which are rare today.

What happens in aortic valve failure?

 Volume overload occurs in the left ventricle of the heart due to the blood leakage of
the aortic valve backwards. If the process is slow, the left ventricle tries to tolerate this
chronic volume overload by loosening and expanding its volume.
Thanks to the expansion and relaxation in the left ventricle, the accumulation of blood in the tissues
behind the heart (left atrium and lungs) is tried to be prevented and the patient does
not complain.
The size of the heart continues to grow stealthily. After a while, the
contraction functions of the heart also begin to deteriorate and the patient enters the
heart failure picture.

 In sudden aortic insufficiency (such as infective endocarditis and acute aortic
dissection extending to the valve), the patient enters the pulmonary edema and
cardiogenic shock table in a short time because the heart does not have enough time to
adapt itself to this situation.

What complaints are seen in aortic valve insufficiency?

 Mild aortic insufficiency does not cause any complaints in the patient. Since moderate
and severe aortic insufficiency is also insidious, it does not cause complaints in the
patient for many years. Usually the first complaint is shortness of breath with effort,
which indicates a decrease in the contraction power of the left ventricle. Patients also
develop complaints of waking up at night with shortness of breath, discomfort from
the jolt caused by heartbeats when they lie on their left side, and chest pain. Severe
heart failure takes many years to develop.

Is aortic valve failure fatal?

 Within 10 years of the onset of aortic valve failure, half of the patients die. In patients
with heart failure, 20 out of 100 patients lose their lives every year.


Where is the mitral valve located, what is its function and how does it work?

 The blood that comes to the left atrium of the heart through the pulmonary veins by
oxygenating in the lungs fills the left ventricle to be pumped to the whole body by
passing through the mitral valve leaflets that are opened.

 The left ventricle is the cavity of our heart with the strongest muscle tissue. Thanks to
the high pressure created by the contraction of the left ventricle, it is possible to send
blood to the extreme points of our body. With the effect of this high pressure, the
aortic valve leaflets are opened and pumped into the blood (forward), while the closed
mitral valve leaflets do not allow it to escape to the left atrium (backward).

 The mitral valve has two leaflets. These leaflets are attached to a ring-like structure
from their base. The free edges of the leaflets attach to the muscle structures (papillary

muscles) in the left ventricle with rope-like structures (korda tendineae). Thanks to
this structure of the valve, it is ensured that the free edges of the leaflets do not drain
the blood back despite the high left ventricular pressure.
This structure is similar to a person (papillary muscles) floating in the air attached to the parachute (mitral valve leaflets) with ropes (chordal tendinae). The pressure of the air (blood in the left
ventricle) allows the parachute to open (the mitral valve leaflets close).
The adhesion of the mitral valve to the muscles in the left ventricle with rope-like structures
prevents the valve from being inverted by the pressure effect.


What does it mean if there is a stenosis in the mitral valve and what happens if there is a
mitral stenosis?

 All pathologies that prevent the mitral valve leaflets from opening freely during the
passage of blood from the left atrium to the left ventricle cause stenosis in the mitral

 The main problem in mitral stenosis is that the valve cannot be opened sufficiently due
to the leaflets adhering to each other, and therefore the passage of blood from the left
atrium to the left ventricle becomes difficult.

 The left atrium begins to contract more strongly to send blood to the left ventricle due
to the narrowed valve, and after a while, it expands, and hardening develops in the
pulmonary veins that bring blood to the left atrium. Due to the hardening of the lung
tissue, the pressure in the lung artery increases and over time, the right ventricle
begins to have difficulty pumping blood to the lung. After a while, the tricuspid valve
develops insufficiency, and the right side of the heart goes to insufficiency.

 An important problem in mitral stenosis is the frequent occurrence of a rhythm
disorder called atrial fibrillation.

 If we compare the normal sinus rhythm to a smooth wave formation created by a drop
of water falling into a still lake, atrial fibrillation is similar to raining on the lake. Due
to the chaotic rhythm, the contraction of the atria of the heart is disrupted. Clots are
formed due to the stagnation of blood in the left atrium. The escape of these clots to
the arm and leg arteries may lead to gangrene, the escape to the brain may lead to
paralysis, the escape to the kidney arteries may lead to kidney failure, and the escape
to the arteries feeding the intestines may lead to necrosis in the intestines. All of these
clinical pictures are life-threatening.

 The normal mitral valve area (MKA) in adults is in the range of 4.0-5.0 cm2.

 Mild mitral stenosis: Complaints begin in the range of MKA 1.4-2.5 cm2. ... The first
complaints are shortness of breath, weakness and rapid fatigue in heavy exercise.

 Medium mitral stenosis: In the range of MKA 1.0-1.4 cm2. During exercise or lying
on your back, shortness of breath begins to wake you up at night with shortness of
breath. Some patients may develop pulmonary edema after exercise (the patient feels

as if water is filled into all airways, he/she cannot breathe. It is a life-threatening

 Severe mitral stenosis: MKA below 1.0 cm2. Even at rest, shortness of breath,
fondness, bed addiction develops. If secondary pulmonary hypertension develops in
mitral stenosis, the progression to right heart failure (edema in the legs, enlargement of
the liver and accumulation of fluid in the abdomen) begins.

What are the causes of mitral stenosis, what is the course of mitral stenosis?

 The most common cause of mitral stenosis is acute rheumatic fever in childhood.
 Mitral stenosis occurs years after the first rheumatic fever attack.
 Most of the patients have their first acute rheumatic fever attack around the age of 12.
Clinical findings of mitral stenosis in these patients begin to be detected around the
age of 20. Complaints related to mitral stenosis occur in patients in their 30s.
 In patients with mitral stenosis, there is a progression to end-stage heart failure
(NYHA class-IV functional capacity) in about 7-10 years after the first appearance of
 If no intervention is made for mitral stenosis, these patients die at an average age of
40-50 years.


What does it mean if there is a deficiency in the mitral valve and what happens if there is a
deficiency in the mitral valve?

 Causes such as a rupture in the strings (chorda tendinea) fixing the free ends of the
mitral valve to the papillary muscles in the left ventricle, dysfunction or tear in the
papillary muscles, tear or hole in the valve leaflets cause insufficiency in the mitral
valve. In case of severe expansion in the annulus-like structure to which the mitral
valve leaflets are attached, the free edges of the two leaflets cannot establish a
solid contact with each other during closure and mitral valve insufficiency

 The main problem in mitral insufficiency is that both the left atrium and the left
ventricle have to cope with this high amount of blood volume due to the blood
escaping back from the left ventricle.

 Mitral insufficiency can be divided into acute mitral insufficiency and chronic
mitral insufficiency according to the duration of development of the pathology:

i. Chronic mitral insufficiency

 Since the process is very slow in chronic mitral insufficiency, the left ventricle
gradually begins to increase its internal volume to adapt to this situation. Due to this

adaptation, patients do not have any complaints for many years. However, after a
while, the left ventricle, which has grown sneakily, starts not contracting well enough
and complaints arise in the patient.

 The degree of mitral insufficiency is defined as mild, moderate, advanced according to
the amount of blood that escapes back.
 Generally, the first complaints that occur are shortness of breath with effort.
 Rhythm problems (atrial fibrillation) may also be seen in chronic mitral insufficiency.
 As in mitral stenosis, the clinical course progresses as high blood pressure in the
pulmonary artery, growth in the right ventricle and progressing to tricuspid valve
failure, but unlike mitral stenosis, growth and failure also occur in the left ventricle of
the heart in chronic mitral insufficiency.
 Mitral valve collapse (mitral valve prolapse) is the collapse of the valve towards the
left ventricle during closure. It doesn't always lead to mitral regurgitation. This
condition is quite common (it is found in 1-2.5% of the population).
ii. Acute mitral insufficiency
 Unlike chronic mitral insufficiency, it is a sudden condition.
 The heart doesn't have enough time to adapt.
 Due to the sudden failure in the mitral valve, complaints and findings occur in the
veins (pulmonary veins) that bring clean blood from the lungs due to rapid blood
pressure increase.
 The picture is dramatic.
 Causes of acute mitral regurgitation:
a. There is a rupture in the rope-like structures (chorda tendinea) holding the mitral leaflets,
b. A microbial infection causing puncture or tear in the leaflets (infective endocarditis),
c. Development of dysfunction or rupture in the muscles (papillary muscles) where the valve
is tied with ropes due to acute heart attack.


 The heart is located between the right atrium and the right ventricle,
 The tricuspid valve consists of three leaflets.
 They resemble mitral valve in structure and way of working,
 Problems in the tricuspid valve may be congenital or acquired.
 The most common cause of acquired tricuspid valve problems is that valve problems
on the left side of the heart lead to enlargement of the right ventricle over the years,
and as a result, there is an opening between the leaflets of the valve during closure due
to the enlargement of the ring-like ring to which the tricuspid valve is attached. In this
case, which is called functional failure, the most common surgical method is to narrow
the valve ring again by inserting a prosthetic ring.

 Tricuspid insufficiency also develops in 10-50% of patients with mitral valve
 Especially in substance addicts, microbial infection-related insufficiency is
common in the tricuspid valve.
 Tricuspid valve failure may develop due to blunt traumas.

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