Heart Structure Tests

In adult cardiology, structural heart disease usually pertains to disorders of the valves of the heart or to holes in the heart that should have closed either during gestation or shortly after birth.

The most common forms of structural heart disease seen in adults in the United States are disorders of the aortic and mitral valves. Less commonly treated structural heart disorders include patent foramen ovale is and atrial septal defects.

The aortic valve is between the heart's pumping chamber and the aorta, the main blood vessel that brings blood to the entire body. Its function keep blood from flowing back into the heart as the heart's pumping chamber relaxes.

The most common aortic valve disorder is aortic stenosis, in which the leaflets of the aortic valve become calcified over time and don't allow the valve to open appropriately. Less common, though just as important, is aortic regurgitation, in which the valve is leaky and allows blood to flow backward from the aorta back into the heart.

The most common symptoms of aortic stenosis are chest pain with exertion, shortness of breath with exertion, dizziness or passing out, particularly during or immediately after exertion, and fatigue.

Aortic stenosis is usually diagnosed because the patient has symptoms, as noted above, or because your doctor hears a heart murmur. In these cases, your cardiologist will likely order an echocardiogram or an ultrasound of the heart.

No known medications slow the progression of aortic stenosis. If you have mild aortic stenosis, your cardiologist will monitor it with regular heart ultrasounds. Once symptoms appear or are severe on ultrasound, treatments include aortic valve surgery or transcatheter aortic valve replacement.

Because transcatheter aortic valve replacement is a relatively new technique, and because the very long-term outcomes of this form of valve replacement are somewhat unknown, surgical aortic valve replacement remains the standard of care for patients at low risk for surgery based on things like age and other medical conditions the patient might have. Patients at intermediate or high risk for surgery are candidates for transcatheter aortic valve replacement.

Because transcatheter aortic valve replacement is a new technique, a cardiac surgeon is always present during valve placement. In most centers, the procedure is performed by one interventional cardiologist and one cardiac surgeon.

Talk to your treating cardiologist and cardiac surgeon about whether you are a candidate for transcatheter aortic valve replacement. Currently, patients who are at low risk for surgery should undergo surgical aortic valve replacement. However, clinical trials are ongoing to evaluate whether low-risk patients should be offered transcatheter aortic valve replacement.

The mitral valve is the valve located between the pumping chamber of the heart and the left atrium, which is the chamber of the heart that collects blood from the lungs and holds it until the pumping chamber is ready to accept it. The mitral valve is important because it keeps blood from being forced back into the lungs when the heart's pumping chamber pumps.

The most common mitral valve disorder in the United States is mitral regurgitation, in which the valve is leaky and allows blood to flow backward into the lungs when the main pumping chamber pumps. Mitral stenosis, where the valve is narrowed, is becoming increasingly rare.

Most people with severe mitral regurgitation complain of shortness of breath, palpitations, or a fluttering feeling in the chest due to an arrhythmia or fatigue.

Mitral regurgitation is often diagnosed because of the symptoms noted above or because your doctor hears a heart murmur. Your cardiologist will likely order an ultrasound of the heart cold and echocardiogram, which can definitively diagnose mitral regurgitation.

Medication doesn't slow mitral regurgitation down. Your cardiologist will monitor it with echocardiograms to see if it's mild or moderate. For severe cases, open heart surgery may be necessary. Repairing the valve is common, but sometimes, it needs replacement. Discuss options with your surgeon, including minimally invasive techniques. A non-surgical alternative is MitraClip, a procedure for those unsuitable for surgery. It involves placing a clip in the valve through a vein in the groin.

A PFO is present in everyone at the time of birth. When you are a fetus, there is no need for blood to be sent to the lungs because you get all your oxygen from your mother's blood. A flap between two heart chambers allows blood to be diverted as it returns to the heart to be sent back to the body. At the time of birth, the pressures in the heart change rapidly, and this flap normally closes and scars over. In about 20% of people, however, the flap remains open. This is called a patent foramen ovale.

PFOs are not dangerous in most people and are usually detected when someone undergoes a heart ultrasound for another reason. However, in a very small subset of people with a PFO, a blood clot that forms in the leg can cross over this flap and cause a stroke. Closure of the PFO is currently recommended in people for whom a stroke is thought to have occurred because of a PFO.

Nearly everyone with a PFO is asymptomatic. As noted above, a small subset of people with PFO can develop strokes.

PFO closure should only really be performed in people who have a stroke thought to be related to the PFO in whom an extensive search for other causes of stroke has not revealed any other potential source of the stroke.

PFO closure is performed in the hospital. The devices are implanted via the large vein in the groin, and an ultrasound camera in the other large vein in the groin provides guidance. Most people go home the same day, and the procedure is usually very well tolerated. It is done under sedation. Patients will need to be on aspirin and a second blood thinner for at least a month and then on aspirin indefinitely.

As opposed to PFOs, ASDs are quite rare. They are never normal and occur due to problems with the development of the heart, in which the wall between the atria does not fully form.

Most people with ASD are asymptomatic until later in life. Sometimes, patients will develop shortness of breath.

ASDs are usually seen by echocardiogram. If you are diagnosed with ASD, your cardiologist will most likely order a transesophageal echocardiogram. This is done in the hospital under sedation and gives a much better view of the ASD and the wall between the atria.

Not every ASD needs to be closed. If the ASD is quite small, most people can be followed with routine echocardiograms to evaluate for worsening heart problems. If blood flow through the ASD appears to be affecting the right side of the heart, patients should have their ASD closed.

ASD closure is performed either through severe open-heart surgery or through the large vein in the groin. Many patients can be treated without having open heart surgery, but the approach depends largely on the shape and size of the ASD as well as its location in the wall between the atria. You should talk to your cardiologist about whether surgery or procedure suits you.