Aortic Valve Insufficiency

[Darwin__0]

  I am a 43 year old male and learned for the first time in July of this year that I had a heart murmur.  An echocardiogram showed that I have leakage of the aortic valve and that my left ventricle is dilated.  I think the numbers quoted to me were 5.3 when the muscle is contracted and 7.1 relaxed.  I have never been told the quantity of regurgitation.  A TEE showed that I have a bicuspid aortic valve.  Prior to this diagnosis I had no syptoms (symptoms) that I was aware of.  In fact, 5 months earlier, I had started an exercise training program and was doing a cardio routine at 140-150 heart beats per minute and a strength training program where I was gradually increasing weights in a full body workout.  I have been feeling better than I have in years.  I am being advised that I need valve replacement surgery.  I have several questions.
  1.  Is there any reason to believe that the exercise routine I started caused or exacerbated the leakage in the valve or the dilation of the ventricle?
  2.  If question 1 is yes, is there any chance that a reduced program will result in the size of my ventricle returning to a more normal size.
  3.  Is repair of the valve an option, rather than replacement?
  4.  How do I find out if I would be a candidate for the minimally invasive techniques that are being used now?

[Cleveland Clinic, MD]

Dear  Darwin,
The aortic valve is the valve that separates the left ventricle from the aorta.  It is made of 3 leaflets or flaps that look like an peace symbol when the valve is closed.  A bicuspid aortic valve means that there are 2 leaflets instead of the usual 3.  A unicuspid valve means there is only one leaflet.   Bicuspid aortic valve is the most common congenital anomaly of the heart.  These valves are functional at birth and remain so throughout a normal life span.  There is a increased predisposition to progress to stenosis (narrowing) as an older adult (60-70’s) and surgical repair may be required at that time.  Replacement is not generally required until the valve has an area of less than 1 cm2.  There is also some increase in the incidence of infective endocarditis (infection of the valve).
Q: Are there any physical restrictions for individuals with bicuspid aortic valve?
A: No.  
Q: Is there any reason to believe that exercise can cause or exacerbated the leakage already in the valve or the dilation of the ventricle?
A: No.  Exercise does not precipitate deteriotion of valves.  
Q: Are there any special diet restrictions?
A: No.
Q: Are there some people who have had bicuspid aortic valve who will never have to have a valve replacement or will everyone with this problem eventually have to get their valve replaced?
A: Only a small percentage of people with this condition will eventually need surgery.
Q: What type of replacement valve is best should surgery be required?
A: The choices are a bioprosthetic valve (from an animal), a mechanical valve, or a homograft (from a human cadaver).  Each has benefits and risks.  The benefit of the bioprosthetic and homograft are that anticoagulation with a blood thinner is not required.  This may be useful in women of child-bearing age who desire to become pregnant and older persons with a high risk of falling.  The disadvantage of these valves is that their life-span is only about 10 years.  The advantage of the mechanical valve is that the life-span is much longer (usually longer than the patients) but requires taking an anticoagulant.  
It is a highly individualized choice as to which valve and will depend upon the patient's preference, the practice of the hospital where the surgery takes place and the co-existing medical problems.  The final decision as to which valve to use will be made by the surgeon in the OR once the valve is exposed and clearly seen.
Q: Is repair of the valve an option, rather than replacement?
A: Aortic valve repair is not a mainstream surgery but is being done at some centers. Essentially what this surgery involves is a detachment of the valve from the aorta and reattachment to a graft.  The benefit of the operation is the preservation of the native aortic valve. This type of operation is not commonly done but may be a good option  depending on the particulars of the case.   In any case it would be wise to have the operation at a major medical center with experience with the operation. The following article has additional information about valve repair and can be obtained at your local medical library.
Pepper J.  Yacoub M. Valve conserving operation for aortic regurgitation.  Journal of Cardiac Surgery.  12(2 Suppl):151-6, 1997 Mar-Apr.

Q: How do I find out if I would be a candidate for the minimally invasive techniques that are being used now?
A: You would first need to be evaluated by a cardiologist who would make recommendations to you and the surgeon.  The final choice would be up to the surgeon doing the operation. If you would like to be seen here I would recommend Dr. Cosgrove or Dr. Lytle (http://www.ccf.org/heartcenter/staff/thoracic.htm).  Surgical appointments can be made through the surgery scheduling office at [phone].

More information about congenital valve abnormalities can be found in  the web sites below.
http://www.amhrt.org/Heart_and_Stroke_A_Z_Guide/conghd.html
http://155.37.5.42/eAtlas/CV/579b.htm
http://www.mamc.amedd.army.mil/WILLIAMS/CHEST/Cardiac/Congenital/Bicuspid/Bicuspid.htm
http://www.cachnet.org/messages2/3292.html
http://www.mch.com/pihc5-06.htm
Hope this helps.
Information provided here is for general educational purposes only. Only your doctor can provide specific diagnoses and treatments. If you would like to be seen at the Cleveland Clinic, please Call 1 - 800 - CCF - CARE for an appointment at Desk F15 with a cardiologist.

Dr. Cosgrove