Heart & Circulation

Heart Valve Disease: Symptoms, Causes, Diagnosis, and Treatment

A patient guide to heart valve disease — covering how valves work, stenosis vs regurgitation, aortic stenosis, mitral regurgitation, heart murmurs, valve repair, mechanical and tissue replacement, TAVI, and the relationship to heart failure and atrial fibrillation.

16 min read

Heart Valve Disease: Symptoms, Causes, Diagnosis, and Treatment

The heart has four valves — the aortic, mitral, tricuspid, and pulmonary valves — that act as one-way doors controlling the flow of blood through the heart’s chambers and out to the body and lungs. When a valve does not open or close properly, blood flow becomes inefficient and the heart must work harder to compensate.

Heart valve disease is common. Mild valve abnormalities are present in a significant proportion of the adult population and often require only monitoring. Moderate-to-severe valve disease, however, can progressively weaken the heart, lead to heart failure and arrhythmias, and — without treatment — can be life-threatening.

How the Heart Valves Work

The heart beats in a coordinated sequence:

  1. Right heart: Deoxygenated blood returns from the body to the right atrium → flows through the tricuspid valve into the right ventricle → pumped through the pulmonary valve into the lungs to receive oxygen.
  2. Left heart: Oxygenated blood returns from the lungs into the left atrium → flows through the mitral valve into the left ventricle → pumped through the aortic valve out to the body via the aorta.

Each valve opens to allow forward flow and closes firmly to prevent backflow. Valve disease disrupts this mechanism in two principal ways.

Stenosis vs Regurgitation

Stenosis — the valve opening is narrowed and stiff, restricting forward blood flow. The heart must generate higher pressure to force blood through the narrowed valve, increasing its workload. Over time, the heart muscle thickens and eventually may weaken and fail.

Regurgitation (or insufficiency) — the valve does not close properly, allowing blood to leak backwards. The chamber behind the leaking valve must handle an extra volume of blood on every beat. This volume overload causes progressive chamber enlargement and, eventually, weakening.

A valve may have both stenosis and regurgitation simultaneously (mixed valve disease).

Aortic Stenosis

The most common significant valve disease in developed countries, particularly in older adults.

What it is

The aortic valve — between the left ventricle and the aorta — becomes narrowed due to progressive calcification and thickening of the valve leaflets. The most common cause in adults over 65 is degenerative calcification (a process similar to calcium deposits in arteries). In younger adults, aortic stenosis more commonly results from a bicuspid aortic valve — a congenital variant in which the aortic valve has two leaflets instead of the usual three, making it prone to earlier calcification.

Symptoms

Aortic stenosis is often silent for years. When severe, it produces a classic symptom triad:

  1. Angina — chest pain on exertion; the thickened heart muscle outstrips its blood supply
  2. Syncope — fainting on exertion; the narrowed valve limits cardiac output when demand rises
  3. Breathlessness — the hallmark of developing heart failure from valve disease

The appearance of symptoms in aortic stenosis marks a critical point: natural history changes dramatically once symptoms develop — without valve intervention, average survival is substantially reduced and the risk of sudden cardiac death rises.

Diagnosis

  • Echocardiogram: measures the valve area, pressure gradient across the valve, and ejection fraction — the key investigations for grading severity as mild, moderate, or severe
  • Doppler assessment: quantifies peak velocity and mean gradient across the valve
  • CT calcium scoring of the aortic valve: used to confirm severity when echocardiographic findings are discordant

Treatment

  • Mild–moderate aortic stenosis, or severe but asymptomatic with preserved ejection fraction: regular echocardiographic surveillance (every 1–5 years depending on severity) and risk factor management
  • Severe aortic stenosis with symptoms (or significant decline in ejection fraction): valve intervention is recommended promptly
    • TAVI (Transcatheter Aortic Valve Implantation) — minimally invasive catheter-based valve replacement; now the standard approach for most patients over 75 and for many intermediate-risk patients
    • Surgical aortic valve replacement (SAVR) — open-heart surgery; preferred for younger patients (under approximately 70), those with concomitant surgical indications, or anatomical factors unsuitable for TAVI

Mitral Regurgitation

The most common valve condition globally, affecting a significant proportion of adults across all age groups.

What it is

The mitral valve — between the left atrium and left ventricle — does not close completely, allowing blood to leak back into the left atrium during each heartbeat. The atrium and ventricle must handle extra volume, progressively enlarging both chambers. Eventually the left ventricle may weaken and heart failure develops.

Primary mitral regurgitation — the valve itself is structurally abnormal:

  • Mitral valve prolapse (MVP) — the most common cause in developed countries; one or both leaflets billow back into the atrium; most cases are mild and benign, but severe prolapse can cause significant regurgitation
  • Chordal rupture — a tendon supporting the valve leaflet tears, causing acute or sudden worsening of regurgitation

Secondary (functional) mitral regurgitation — the valve leaflets are structurally normal but do not close properly because the left ventricle has dilated (from cardiomyopathy or after a heart attack), pulling the leaflet attachment points apart.

Symptoms

Mild mitral regurgitation is usually asymptomatic. When severe:

  • Breathlessness on exertion, progressing to breathlessness at rest
  • Fatigue and reduced exercise tolerance
  • Palpitations — atrial fibrillation is a common complication of mitral regurgitation
  • Signs of heart failure (ankle swelling, orthopnoea)

Treatment

  • Mild–moderate or asymptomatic severe MR with preserved left ventricular function: regular surveillance
  • Severe MR with symptoms, declining ejection fraction, or progressive left ventricular enlargement: valve intervention recommended
    • Surgical repair — preferred over replacement for primary MR when technically feasible; repair preserves the native valve and has superior long-term outcomes
    • Surgical replacement — when repair is not possible; mechanical or tissue valve
    • Transcatheter edge-to-edge repair (TEER, MitraClip) — a catheter-based procedure that clips the mitral leaflets together to reduce regurgitation; used in high-risk surgical patients with primary MR, or in selected patients with secondary MR causing persistent symptoms despite optimal medical therapy

Aortic Regurgitation

The aortic valve does not close properly, allowing blood to leak back from the aorta into the left ventricle during diastole (the relaxation phase). This volume load causes progressive left ventricular enlargement.

Causes

  • Bicuspid aortic valve
  • Aortic root dilation (as in hypertension, Marfan syndrome, or aortic aneurysm)
  • Infective endocarditis (infection destroying valve tissue)
  • Rheumatic heart disease

Symptoms

Aortic regurgitation can be silent for many years as the left ventricle compensates by enlarging. When the ventricle begins to fail:

  • Breathlessness and reduced exercise tolerance
  • Palpitations (the hyperdynamic left ventricle generates visible and palpable pulsations)
  • Heart failure symptoms

Treatment

  • Regular echocardiographic surveillance
  • Surgical aortic valve replacement when symptoms develop or when left ventricular function or dimensions reach specified threshold criteria — even in the absence of symptoms, to prevent irreversible damage

Mitral Stenosis

Narrowing of the mitral valve restricts blood flow from the left atrium to the left ventricle. In developed countries, most cases result from rheumatic heart disease — valve scarring caused by rheumatic fever following untreated Group A streptococcal infection in childhood. Mitral stenosis remains common in parts of Asia, sub-Saharan Africa, and Latin America.

Symptoms

  • Breathlessness on exertion — the left atrium cannot empty efficiently, raising pulmonary pressures
  • Palpitations — atrial fibrillation is a common and important complication
  • Haemoptysis (coughing blood) in advanced disease
  • Stroke risk, particularly with coexistent atrial fibrillation

Treatment

  • Percutaneous mitral balloon valvuloplasty (PMBV) — a catheter-based procedure to expand the narrowed mitral valve; highly effective in rheumatic mitral stenosis with favourable anatomy
  • Surgical repair or replacement — when PMBV is not appropriate or anatomy is unfavourable
  • Anticoagulation for stroke prevention, particularly when atrial fibrillation is present

Tricuspid Valve Disease

The tricuspid valve — between the right atrium and right ventricle — is most commonly affected by secondary tricuspid regurgitation (a leaking valve caused by enlargement of the right heart due to left-sided heart disease, pulmonary hypertension, or heart failure). Primary tricuspid disease is less common.

Mild tricuspid regurgitation is very common and usually requires no specific treatment beyond managing the underlying cause. Severe symptomatic tricuspid regurgitation causing right heart failure (fluid retention, liver congestion, fatigue) may require tricuspid valve repair or replacement — either via open surgery or through emerging transcatheter tricuspid interventions available at specialist centres.

Heart Murmurs

A heart murmur is the sound made by turbulent blood flow through the heart. When detected through a stethoscope, it prompts further investigation — usually an echocardiogram.

Not all murmurs indicate disease. Many are:

  • Innocent (functional) — produced by fast flow through a structurally normal valve; common in children, pregnancy, and athletes; no treatment needed
  • Flow murmurs — caused by anaemia or fever increasing cardiac output

Murmurs that warrant echocardiography:

  • Any diastolic murmur (always abnormal)
  • Loud systolic murmurs (grade 3 or above)
  • Murmurs accompanied by symptoms (breathlessness, syncope, chest pain, reduced exercise tolerance)
  • Murmurs in people with risk factors for valve disease (bicuspid aortic valve, prior rheumatic fever, connective tissue disorders, prior endocarditis)

If you have been told you have a murmur and have not had an echocardiogram, ask your doctor whether one is indicated.

Diagnosis

Echocardiogram (Heart Ultrasound)

The central investigation for valve disease. An echocardiogram:

  • Identifies the affected valve(s) and the type of lesion (stenosis or regurgitation)
  • Grades severity (mild, moderate, severe) using standardised measurements
  • Assesses the consequences for heart chamber size and function (including ejection fraction)
  • Guides the timing of intervention

Transoesophageal echocardiography (TOE/TEE) — where the probe is passed into the oesophagus — provides closer, more detailed imaging. It is used to plan surgery and transcatheter procedures, assess valve anatomy in detail, and diagnose endocarditis.

CT Imaging

CT is essential for planning TAVI and other catheter-based procedures (measuring anatomy, valve dimensions, and vascular access routes). Cardiac MRI can provide additional structural information in complex cases.

Exercise Testing

Used to unmask symptoms in apparently asymptomatic patients — for example, to confirm whether a patient with severe aortic stenosis is truly symptom-free. An abnormal blood pressure response or exercise-induced symptoms may bring forward the recommendation to intervene.

Treatment: Overview

Treatment decisions are guided by:

  1. Valve lesion type and severity (measured by echocardiogram)
  2. Presence and severity of symptoms
  3. Heart function — whether ejection fraction is preserved or declining
  4. Chamber size — progressive enlargement can trigger intervention even before symptoms develop
  5. Patient factors — age, comorbidities, surgical risk, and patient preference

Monitoring (Conservative Management)

For mild or moderate valve disease, or for asymptomatic severe disease with preserved heart function, regular echocardiographic surveillance is appropriate. The interval depends on severity and type of lesion.

Valve Repair

Repair is preferred over replacement when technically feasible:

  • Preserves the native valve structure
  • Associated with better long-term heart function
  • Avoids the need for long-term anticoagulation (required with mechanical valves)
  • Standard of care for primary mitral regurgitation at specialist centres

Valve Replacement: Mechanical vs Tissue Valves

When repair is not possible, a diseased valve is replaced with one of two options:

Mechanical valves:

  • Durable — designed to last a lifetime, avoiding future reoperation
  • Require lifelong anticoagulation with warfarin — a commitment to regular INR blood tests and management of bleeding risk
  • Preferred in younger patients (generally under 50–60 years) where durability over decades is the priority

Tissue (biological) valves:

  • Made from animal tissue (typically porcine or bovine pericardium)
  • Do not require long-term warfarin (aspirin only after a settling period, unless another anticoagulation indication exists)
  • Deteriorate over time — may require replacement after 10–20 years; the younger the patient at the time of implant, the higher the likelihood of needing a future reoperation
  • Preferred in older patients, those with contraindications to warfarin, or those at high bleeding risk

TAVI — Transcatheter Aortic Valve Implantation

TAVI (also called TAVR — Transcatheter Aortic Valve Replacement, the terminology used in the United States and in Australian clinical trials) is a minimally invasive catheter-based procedure that replaces the diseased aortic valve without open-heart surgery.

How it works:

  • A new tissue valve, mounted on a collapsible stent frame, is compressed and loaded into a catheter
  • The catheter is typically inserted via the femoral artery in the groin under X-ray and echocardiographic guidance
  • The new valve is deployed inside the diseased native aortic valve, pushing it aside and taking over its function
  • The procedure is performed under sedation or general anaesthesia; most patients are mobile and able to go home within one to three days

Who is it for? TAVI was initially developed for patients too high-risk for open surgery. Large randomised trials have since established TAVI as appropriate — and in many centres preferred — for intermediate- and lower-risk patients, particularly those aged over 75. Current ESC and AHA/ACC guidelines recommend TAVI as the preferred approach for most symptomatic patients with severe aortic stenosis over 75 years.

Other transcatheter valve procedures:

  • MitraClip (TEER) — transcatheter edge-to-edge mitral repair for mitral regurgitation in high-risk surgical patients
  • Transcatheter tricuspid interventions — an emerging field for severe tricuspid regurgitation

Relationship to Heart Failure

Valve disease is a major cause of heart failure:

  • Aortic stenosis → sustained pressure overload → left ventricular hypertrophy → eventual systolic and diastolic dysfunction → heart failure
  • Mitral regurgitation → chronic volume overload → left atrial and ventricular dilation → declining ejection fraction → heart failure
  • Secondary mitral regurgitation → arises in the context of underlying cardiomyopathy and heart failure; the two conditions worsen each other and management must address both

Treating the valve lesion at the appropriate time — before irreversible damage to the heart muscle — is the primary goal of ongoing surveillance and timely intervention.

See: Heart Failure: Symptoms, Causes, Diagnosis, and Treatment

Relationship to Atrial Fibrillation

Valve disease — particularly mitral valve disease — is one of the strongest risk factors for atrial fibrillation. The enlarged left atrium that develops as a consequence of mitral regurgitation or stenosis becomes an electrical environment prone to AF. Aortic stenosis, with its pressure-overloaded left ventricle, also increases AF risk.

Conversely, AF worsens valve disease outcomes — the irregular rhythm reduces cardiac output, increases heart failure risk, and raises stroke risk significantly (compounded in the presence of mitral stenosis or regurgitation).

People with both valve disease and AF typically require anticoagulation — both for AF-related stroke prevention and, after mechanical valve implantation, to prevent valve thrombosis.

Infective Endocarditis: An Important Complication

Infective endocarditis — a bacterial (or, rarely, fungal) infection of the heart valves — is more common in people with structural valve disease. Bacteria adhere to abnormal valve surfaces, forming infected deposits (vegetations) that can rapidly destroy the valve and embolise to other organs including the brain.

Prevention: People with specific high-risk conditions — including mechanical or biological prosthetic valves, and some repaired or unrepaired structural heart lesions — should receive antibiotic prophylaxis before certain dental procedures. Discuss with your cardiologist whether this applies to you.

Symptoms of endocarditis include prolonged fever, chills, fatigue, night sweats, a new or changing heart murmur, and occasionally visible skin changes (splinter haemorrhages under the nails, red tender nodules on the fingers or toes). Seek urgent medical assessment if these symptoms develop.

FAQ

Q: If I have a heart murmur, does that mean I have valve disease? Not necessarily. Many murmurs are innocent and require no treatment or ongoing surveillance. A murmur that is diastolic, loud, or accompanied by symptoms warrants investigation with an echocardiogram. Your GP or cardiologist can advise based on the murmur’s characteristics and your overall clinical picture.

Q: How often do I need a follow-up echocardiogram for valve disease? This depends on the type and severity. Mild disease may need surveillance every three to five years; moderate disease every one to two years; severe disease — especially when approaching the threshold for intervention — may need follow-up every six to twelve months. Your cardiologist will advise on the appropriate schedule.

Q: If I need valve surgery, how long is the recovery? After open-heart valve surgery, most people spend five to ten days in hospital and require six to twelve weeks of recovery before returning to normal activities. TAVI recovery is faster — most people go home within one to three days and are largely back to normal within a few weeks. Cardiac rehabilitation is recommended after all major cardiac procedures.

Q: Do I need lifelong warfarin after valve replacement? This depends on the valve type. Mechanical valves require lifelong anticoagulation (warfarin, or in selected cases a direct oral anticoagulant — your cardiologist will advise). Tissue valves generally require anticoagulation only for the first three months after implantation, then aspirin alone — unless you have atrial fibrillation or another indication for ongoing anticoagulation.

Q: Can I exercise with valve disease? Most people with mild or moderate valve disease can exercise safely. Severe symptomatic aortic stenosis and other advanced valve conditions require more caution — supervised exercise testing may be recommended before independent exercise programmes. After valve repair or replacement, cardiac rehabilitation helps guide a safe return to activity. Always discuss your specific exercise plan with your cardiologist.

Further Reading

Educational only — not a substitute for professional medical advice. Always speak with your cardiologist about your specific valve condition and the appropriate management plan.