Heart Valve Diseases: Understanding Stenosis, Regurgitation, and When Surgery Is Needed

• by Melinda Hawthorne
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When your heart valve doesn’t open or close right, your whole body feels it. You might not notice at first-just a little tired after walking up stairs, or short of breath when you’re doing the dishes. But if one of your heart’s four valves is narrowed (stenosis) or leaking (regurgitation), that small change can grow into something serious. The good news? We know how to fix it. And the earlier you catch it, the better your chances of getting back to normal life.

What Happens When a Heart Valve Fails

Your heart has four valves: mitral, tricuspid, aortic, and pulmonary. Each one acts like a one-way door, making sure blood flows in the right direction. When a valve opens, blood moves forward. When it closes, it stops blood from flowing backward. Stenosis means the valve gets stiff and narrow-like a door jammed shut. Regurgitation means it doesn’t close all the way-like a door that won’t latch, letting air leak back through.

Aortic stenosis is the most common serious valve problem in older adults. About 2% of people over 65 have it. The valve leaflets calcify over time, like rust on a hinge. This forces the left ventricle to pump harder to push blood through the narrowed opening. Severe aortic stenosis is defined by a valve area smaller than 1.0 cm², a pressure difference across the valve greater than 40 mmHg, and blood flow speed over 4.0 m/s. Left untreated, half of people with severe aortic stenosis won’t survive five years.

Mitral regurgitation, on the other hand, is often caused by a valve that won’t seal. Blood leaks back into the left atrium every time the heart contracts. In mild cases, you might feel nothing. But over time, the heart stretches to handle the extra volume. Eventually, fatigue, palpitations, and trouble breathing show up. About 80% of mitral stenosis cases worldwide come from rheumatic fever-still common in places without access to antibiotics. In the UK and US, it’s rare, but not gone.

Stenosis vs. Regurgitation: Key Differences

It’s easy to mix up stenosis and regurgitation because both cause similar symptoms. But they stress the heart in opposite ways.

In aortic stenosis, the heart fights against resistance. It thickens its muscle wall to squeeze blood through a tight valve. That’s why people with this condition often get chest pain (angina), feel faint (syncope), or get winded quickly. The classic trio: angina, syncope, and heart failure-shows up in over 50% of severe cases.

Aortic regurgitation is different. The valve leaks, so blood flows backward into the heart with every beat. The heart doesn’t fight pressure-it fights volume. It has to pump more blood each time to make up for what’s leaking back. People with this condition usually feel their heart pounding (palpitations) and get breathless during activity. They might not notice symptoms until the heart is already enlarged.

Mitral stenosis is rare in the UK but causes a different set of problems. Blood backs up into the lungs because it can’t flow from the left atrium to the left ventricle. That leads to fluid in the lungs, waking you up gasping at night (orthopnea), or needing extra pillows to sleep. Mitral regurgitation, by contrast, often causes vague fatigue. Many patients say, “I just can’t keep up like I used to,” long before they realize it’s a valve issue.

When Surgery Becomes Necessary

Not every leak or narrow valve needs surgery. But when it gets bad enough, waiting too long can be deadly.

For severe aortic stenosis, guidelines say: don’t wait for symptoms. If your valve gradient hits 50 mmHg or your ejection fraction drops-even if you feel fine-intervention is recommended. Studies show 2-year survival drops to 50% if you delay treatment until you’re symptomatic. That’s why doctors monitor asymptomatic patients with echocardiograms every 6 to 12 months.

For regurgitation, the timing is trickier. If the leak is mild and the heart size and function are normal, watchful waiting is fine. But if the left ventricle starts to enlarge or the pumping ability drops, surgery should happen before symptoms appear. Waiting until you’re breathless means the heart may never fully recover.

Surgical Options Today

There are two main ways to fix a bad valve: open-heart surgery or a catheter-based procedure.

Traditional surgical valve replacement involves opening the chest, stopping the heart, and replacing the valve with a mechanical one or a tissue valve. It’s a major operation-3 to 4 hours under general anesthesia, 5 to 7 days in hospital. Recovery takes months. But it’s durable. Mechanical valves last forever but require lifelong blood thinners. Tissue valves don’t need blood thinners (usually) but wear out after 15 to 20 years.

Transcatheter Aortic Valve Replacement (TAVR) changed everything. Now, instead of opening the chest, a new valve is delivered through a small cut in the groin or chest. It’s pushed up the artery and expanded inside the old valve. TAVR is now the first choice for patients over 75, or those with higher surgical risk. The PARTNER 3 trial showed TAVR had 12.6% lower mortality than surgery at five years in low-risk patients. In the US, 65% of aortic valve replacements in people over 75 are now done with TAVR.

For mitral regurgitation, options include repair or replacement. Repair is preferred-it preserves the natural valve and heart function. The MitraClip, a tiny device delivered by catheter, clips the leaflets together to stop the leak. The COAPT trial showed it cut death rates by 32% in patients with functional mitral regurgitation compared to medicine alone. For primary mitral regurgitation (caused by valve damage), surgical repair still offers the best long-term survival-90% at 10 years.

What Recovery Really Looks Like

Patients often think surgery means a quick return to normal. Reality is messier.

After TAVR, many feel better within days. One patient in Cleveland Clinic’s registry said, “I went from struggling to walk to the mailbox to hiking three miles in two months.” That’s common. But even minimally invasive procedures leave scars. Sternotomy pain from open surgery can last 8 weeks. Lifting grandchildren, carrying groceries, or even sleeping on your side takes time.

If you get a mechanical valve, you’ll be on blood thinners for life. INR levels must be checked twice a week at first, then monthly. Too high, and you risk bleeding. Too low, and you risk clots. It’s a daily balancing act.

Many patients feel dismissed early on. A 2022 survey found 28% of people with valve disease say doctors ignored their symptoms until they were nearly collapsed. Fatigue, shortness of breath, and reduced stamina are often written off as “just getting older.” But they’re not. They’re warning signs.

What’s Next for Valve Treatment

The field is moving fast. In March 2023, the FDA approved the Evoque system for tricuspid valve repair-a first. That means now, all four valves can be treated with catheter-based methods. The Cardioband system for mitral annuloplasty is already in use in Europe and entering US trials. The Harpoon system for mitral repair is expected to get FDA approval in 2024.

Durability remains a challenge. Bioprosthetic valves wear out. Current data shows about 21% fail by 15 years. But new tissue treatments are being tested that could extend life to 25+ years. By 2030, experts predict 80% of valve procedures will be done without open surgery.

The big shift? Moving from “fix it when you’re dying” to “fix it before you’re in trouble.” Earlier detection, better imaging, and less invasive tools mean more people can live longer, healthier lives. You don’t have to accept fatigue as normal. If you’ve been told you’re “just out of shape,” ask: could it be your heart valve?