Valvular Disease

Valvular disease comprises disorders of the heart valves in which a valve fails to open fully (stenosis) or to close completely (regurgitation/insufficiency), disturbing intracardiac flow and pressure. Over time these lesions impose chronic pressure or volume overload on the cardiac chambers, driving hypertrophy and remodelling and, if unrelieved, progression to heart failure.

Definition

Valvular heart disease is structural or functional abnormality of one or more cardiac valves producing stenosis (impaired opening), regurgitation (impaired closure), or both, with consequent abnormal loading of the cardiac chambers.

Scope

The entry covers the two basic functional disturbances - stenosis and regurgitation - across the cardiac valves, the principal causes (degenerative/calcific, rheumatic, myxomatous, infective and congenital), the characteristic morphology of the diseased valve, and the haemodynamic consequences for the chambers. It is reference pathology, not clinical management guidance.

Core questions

• What functional disturbances - stenosis and regurgitation - can a diseased valve produce?
• What are the major causes, from calcific degeneration to rheumatic and myxomatous disease?
• How do stenotic and regurgitant lesions impose pressure versus volume overload on the chambers?
• How does chronic valvular overload progress to hypertrophy, remodelling and heart failure?

Key concepts

• Stenosis versus regurgitation
• Calcific (degenerative) valve disease
• Rheumatic heart disease
• Myxomatous degeneration and mitral valve prolapse
• Infective endocarditis and vegetations
• Pressure overload versus volume overload
• Chamber hypertrophy and remodelling

Mechanisms

A valve can fail in two basic ways. Stenosis impedes forward flow and raises the pressure the upstream chamber must generate, producing pressure overload and concentric hypertrophy - as in calcific aortic stenosis, an active, atherosclerosis-like process of valve thickening and calcification. Regurgitation allows backward flow, imposing volume overload and chamber dilation - as in chronic mitral regurgitation from myxomatous degeneration. Causes include age-related calcific degeneration, rheumatic disease following streptococcal infection (with commissural fusion and scarring), myxomatous (mucoid) degeneration, infective endocarditis (destructive vegetations) and congenital malformations such as bicuspid aortic valve. Whatever the cause, sustained abnormal loading drives hypertrophy, remodelling and, eventually, the syndrome of heart failure.

Clinical relevance

Valvular disease is a significant and, with population ageing, increasingly common contributor to cardiovascular morbidity and to heart failure. Understanding the lesions and their haemodynamic effects supports appraisal of the evidence; this entry is descriptive and is not a basis for individual diagnostic or treatment decisions.

Epidemiology

Population-based study has shown that valvular heart disease is common and that its prevalence rises markedly with age, with degenerative (calcific) lesions predominating in higher-income settings and rheumatic disease remaining a major burden in many lower-income regions.

History

For much of the twentieth century rheumatic disease dominated the picture of valvular pathology; with declining rheumatic fever in higher-income countries and population ageing, degenerative calcific aortic disease and myxomatous mitral disease became the leading lesions there, while rheumatic disease persists globally. Recognition that calcific aortic stenosis is an active, regulated biological process rather than passive wear reshaped understanding of degenerative valve disease.

Key figures

• Alec Vahanian
• Maurice Enriquez-Sarano
• Vuyisile T. Nkomo

Seminal works

• nkomo-2006
• vahanian-2021

Frequently asked questions

What is the difference between valve stenosis and regurgitation?

Stenosis means the valve does not open fully, obstructing forward flow and forcing the upstream chamber to work against higher pressure; regurgitation (insufficiency) means the valve does not close fully, allowing blood to leak backward and overloading the chamber with volume.

How does valve disease lead to heart failure?

Stenotic and regurgitant lesions impose chronic pressure or volume overload on the cardiac chambers, driving hypertrophy and remodelling; if the overload persists and compensatory reserve is exhausted, the heart progresses to failure.