Doctor, listen to my heart

Dutch GPs don’t use the stethoscope enough, so they miss heart valve problems. This is the opinion of digital patient platform Hartvolgers following a survey among 8800 European people over 60. The Netherlands scored the lowest in this regard. The stethoscope is used only at one in ten GP visits. Indeed too little, is also the opinion of Mohamed Soliman, cardiothoracic surgeon at the Catharina Hospital in Eindhoven. According to him, it is especially important for people over the age of 60 that GPs listen to the heart, especially those who suffer from shortness of breath or fatigue. “That would reveal many valve problems and would therefore be a great screening method.”

An annual ultrasound

The heart has four valves. Two valves in the left half and two in the right half. The left half of the heart pumps blood to the body; there are the aortic valve and the mitral valve. The right half of the heart pumps blood to the lungs; there are the tricuspid and pulmonary valves. Most problems arise with the valves in the left side of the heart.

A healthy heart valve opens and closes completely so that blood only flows in one direction. A malfunctioning valve is narrowed or leaking. 15 to 25 percent of people over 60 have a narrowing of the aortic valve (stenosis). Between 1 and 2 percent have a leaking mitral valve.

This often comes to light when a doctor listens to the heart with a stethoscope during a routine examination and hears what is known as a heart murmur. The sound is created because the blood flow encounters resistance and as a result starts to swirl. “A noise says nothing about the nature or severity of a valve abnormality,” emphasizes Soliman. “Follow-up testing with an ultrasound is always necessary.”

Heart valve problems don’t have to be serious, but they can become. Once the GP has discovered a valve problem, then an annual ultrasound is necessary for checking, according to Soliman. “If nothing special comes to light, this can take place every other year. Not only GPs often forget to check. Patients often think: I feel fit and have no complaints, so it must be good.”

However, that is not correct. A malfunctioning heart valve can cause wear and tear. With a leaking valve, the blood partially flows back. The heart compensates for this, but has to work harder to pump the same amount of blood. A narrowed valve can cause symptoms such as dizziness, chest pain, tickling cough when lying down, fatigue, an irregular heartbeat and fainting, especially with exertion. A leaking valve allows the body to retain moisture. The result: thick legs, swollen feet and shortness of breath due to fluid behind the lungs. This can cause the heart to get bigger and the heart muscle thinner over time. This leads to a reduced pump function, or heart failure. It is important to anticipate complaints that arise as a result, according to Soliman. “Once the time has come, operating on a leaking heart valve will no longer offer a solution. Unfortunately, I see a patient once or twice a year for whom this applies.”

valve operation

Whether a valve operation is necessary depends on the symptoms and the speed at which they worsen. Unless it is an emergency operation, the specialist will discuss with the patient one or two weeks before the operation which valve and method is most suitable.

If valve surgery is necessary, repair of the own valve is always preferable. If this is not possible, you can opt for a mechanical (artificial) valve or biological valve. Since artificial valves are made of compressed carbon and steel, they hardly wear out and in principle last a lifetime. However, mechanical valves can make a ticking sound, which some people find disturbing. This is less with the latest artificial valves. Another disadvantage is that wearers of a mechanical valve have to take anticoagulants (blood thinners) for life. This reduces the risk of blood clots forming on the heart valve.

Nowadays, a biological valve is usually made of bovine material. The biggest advantage of this is that no blood thinners are needed. They are also noiseless. A disadvantage is that they wear out, so that replacement is necessary after an average of fifteen years.

Too old for surgery

Not all patients are a candidate for open heart surgery. Doctors sometimes decide not to operate because of age, poor heart and kidney function, or concomitant diseases, such as diabetes. “The question then is whether someone will survive such a severe procedure. 2 percent of patients die from heart valve surgery, compared to 1 percent from bypass surgery. In addition, we look at whether an intervention is sensible with a view to the quality of the rest of life,” says Soliman.

Not all people are satisfied with a ‘no’ from the doctor. Every year, dozens of Dutch people move to Belgium to repair or replace leaking heart valves. In 2016, a few dozen Dutch patients received a new heart valve via keyhole surgery in the Flemish Onze-Lieve-Vrouw hospital in Aalst. That is less stressful than open heart surgery. But you don’t always have to go to Belgium for that; Dutch heart centers have also been placing a biological (aortic) heart valve through a small hole in the chest for about five years now.

The technique is called mini-AVR (Aorta Valve Replacement). In addition, you have also been using the TAVI technique for ten years: the replacement of an (aortic) valve via the femoral artery. This also allows a leaking mitral valve to be secured with a staple or Mitral Clip. This method is being used more and more. Not only is the procedure less stressful, patients also recover faster.

However, not everyone gets valve surgery through the groin. This is because there are no results yet from the research into the long-term effects. That is still ongoing. soloman:
“If it shows that a valve through the groin lasts just as long and functions as well as through open-heart surgery, this will become the new standard method.”

My heart valve in a database

There are sixteen heart centers (in hospitals) in the Netherlands, where open heart operations and specialized treatments take place. If you get a new artificial valve, the brand, type and serial number will be recorded at the heart center of the hospital performing the operation. If a production error is discovered in the artificial valve, the heart center can quickly track you down. But more is being recorded. Cardiac surgeons send data from a heart valve operation to a national database: the Dutch Heart Registry. The advantage of this is that the results of the operations are compared. What went well, and what could be done better? In this way, hospitals can learn from each other. Information about the operation results per hospital can be found at www.meetbaarbeter.com and www.nederlandsehartregistratie.nl.

Do the valve check

Pay attention to these complaints
Do you suffer from dizziness, fainting, shortness of breath, tickling cough when lying down, swollen feet, chest pain, irregular heartbeat, fatigue without exertion or dizziness or fatigue with exertion? Maybe it’s a valve defect. Always good to have you examined. However, many people have no complaints with a valve disease.

60-plus? Let the doctor listen to your heart
The risk of valve defects increases with age. If you are over 60, immediately ask your GP if you want to listen to your heart. Once a year is sufficient.

High bloodpressure? Also watch your heart valve
High blood pressure appears to be associated with heart valve problems, according to research from the University of Oxford. Yet another reason to keep a close eye on blood pressure and to treat it if necessary.

Watch out for infection or rheumatism
Valve problems are often congenital, but they can also be caused by a bacterial infection, juvenile rheumatism or acute rheumatism. So it does not hurt to have the doctor listen to your heart once more if you have experienced this.

Menopausal complaints? Maybe it’s your heart valve
As a woman, you have to be extra careful. Women have valve problems just as often as men, but heart problems are more often overlooked because they are confused with menopausal symptoms. They therefore often undergo urgent valve surgery. Have your doctor listen to your heart once a year, especially if you have complaints such as dizziness or fluid retention.

Online information

On the website www.hartklepkeuze.nl is the ‘Heart valve selection aid’ of the Heart Foundation and the Dutch Cardiology Association. Here you will find a lot of practical information about heart valve abnormalities, prostheses and surgery.

To raise awareness about valve problems, the first European Heart Valve Day will take place on 24 September, organized by physician and patient organizations from five countries. www.heartvalveday.eu

This article originally appeared in Plus Magazine March 2018. Not yet a Plus Magazine subscriber? Becoming a subscriber is done in no time!