Congenital Heart Disease | Pediatrics In Review | American Academy of Pediatrics

What Do The Heart's Tricuspid And Bicuspid Valves Do?

Heart valves allow blood to flow one way and prevent it from flowing in the wrong direction. The tricuspid valve controls blood flow between the right atrium and right ventricle. The bicuspid or mitral valve does the same on the left.

The heart consists of four chambers. The left and right atrium are the upper chambers, and the left and right ventricles are the bottom chambers.

Heart valves open to allow blood to flow between the chambers and in and out of the heart. They close to prevent blood from flowing the wrong way.

Each valve has cusps, or flaps of tissue, which open and close to let blood flow through the heart.

This article explores the differences between the tricuspid and bicuspid valves and the problems that can affect them.

The four heart valves open to allow blood to flow into and away from the heart and close to prevent blood from flowing back.

The valves allow the heart to receive blood from the body and pump it to the lungs to oxygenate it. It then pumps the oxygen-rich blood back out of the body.

These valves need to open and close fully and easily with each heartbeat to work properly. Issues with the heart valves can interfere with this function.

Heart valve disease can cause regurgitation, in which a valve does not close completely, and blood can leak backward in the direction it came from.

Heart valves also need to open properly. Aortic stenosis refers to the narrowing and stiffening of the heart valve. This means it cannot open as widely as it should to allow blood to pass through, which restricts the blood flow.

All valves need the right number of cusps to work properly, but sometimes, a cusp may be missing. If the heart cannot pump blood as effectively as it should, it can lead to serious complications, such as heart failure or sudden cardiac arrest.

Tricuspid valve

The tricuspid valve opens to let blood flow from the right atrium to the right ventricle. It closes to prevent blood from flowing from the right ventricle toward the right atrium.

Bicuspid or mitral valve

The bicuspid valve opens to let blood flow from the left atrium to the left ventricle. It closes to prevent blood from flowing from the left ventricle back toward the left atrium.

The bicuspid valve has two cusps, while the other valves have three. Another name for the bicuspid valve is the mitral valve.

Pulmonary valve

The pulmonary valve sits between the right ventricle and the pulmonary artery.

This valve opens to let blood pass from the right ventricle through the pulmonary artery to the lungs to oxygenate the blood.

The pulmonary valve closes to prevent blood from flowing back from the pulmonary artery to the right ventricle.

Aortic valve

The aortic valve sits between the left ventricle and the aorta, which is the major artery carrying oxygenated blood from the heart to the rest of the body.

This valve opens to let blood flow from the left ventricle to the aorta and closes to prevent blood from flowing back to the left ventricle.

The below conditions can affect the tricuspid valve.

Tricuspid atresia

Tricuspid atresia means the heart does not have a tricuspid valve, which means blood cannot flow properly between the right atrium and the right ventricle. People with this condition may have too much or too little blood flow to the lungs.

Treatment for tricuspid atresia may include using a stent to increase blood flow to the lungs, or banding, which narrows the pulmonary artery to decrease blood flow to the lungs.

Tricuspid regurgitation

Tricuspid regurgitation occurs if the tricuspid valve leaks blood back toward the right atrium. Increased blood flow to the right atrium can cause it to enlarge and alter the pressure in the heart.

Tricuspid stenosis

With tricuspid stenosis, the opening of the tricuspid valve narrows and restricts blood flow to the right ventricle. This can negatively affect blood pressure and blood flow in the heart.

Treatment may include regular monitoring of the heart, medications, or surgery to repair or replace the tricuspid valve.

The following conditions can affect the bicuspid or mitral valve:

Mitral valve prolapse

Mitral valve prolapse occurs if the cusps of the bicuspid valve do not close properly and bulge into the left atrium. For severe cases, treatment may include valve repair or replacement.

Mitral valve regurgitation

Mitral valve regurgitation occurs if the bicuspid valve leaks blood back toward the left atrium.

Mitral valve stenosis

Mitral valve stenosis occurs if the bicuspid valve's opening narrows, restricting blood flow to the left ventricle.

Treatment may include medications to treat symptoms and prevent blood clots or surgery to repair or replace the valve.

Heart valves allow blood to flow into the heart, through the chambers, and out to the rest of the body. They also prevent blood from flowing back the wrong way.

The tricuspid valve allows blood flow between the right atrium and the right ventricle. The bicuspid valve allows blood flow between the left atrium and the left ventricle.

Common heart valve disorders include stenosis and regurgitation, which doctors may treat with medication or surgery.

Leaky Heart Valve

A leaky heart valve might go unnoticed. Or it could cause health problems that could be either minor or serious. How serious a leaky heart valve is depends on how much it interferes with normal blood flow through the heart. Treatments include medicines, surgical repair, or surgical replacement of the leaky valve. Observation over time for changes is the most common approach to a leaky heart valve.

The heart has four valves. They include:

tricuspid valve

pulmonic valve

mitral valve

aortic valve

The valves consist of flaps that open to let blood flow in one direction as it moves through the chambers of the heart. Then the valves close to keep blood from flowing backwards into the chamber it just left. Each valve typically has three flaps, except for the mitral valve, which has two.

Any of the four valves can become leaky. This means that just after the heart squeezes and pumps blood forward, some blood will leak backward through the valve. Leaking through the valve is also called valve regurgitation.

A doctor usually diagnoses a leaky heart valve by:

Listening to the heart with a stethoscope for abnormal sounds such as a heart murmur

Looking at the results of a heart ultrasound, also called an echocardiogram

A person's description of symptoms along with the physical exam and echocardiogram can determine how serious a leaky heart valve is.

Frequently, a leaky heart valve causes no symptoms. Many healthy people have one or more valves that are slightly leaky.

If the heart valve leak is severe, it may impair the forward flow of blood. This can cause symptoms of congestive heart failure, which include:

Shortness of breath, especially with exertion or when lying flat

Leg swelling or fluid retention elsewhere in the body

Other symptoms of a leaky heart valve may include:

Lightheadedness

Rapid heartbeat

Heart fluttering or palpitations

Fatigue

Even when there is significant valve regurgitation, there may be no symptoms.

Causes of a leaky aortic valve include:

A bicuspid aortic valve, which means the valve has two flaps instead of the normal three

High blood pressure, or hypertension

Infection of the heart valve, known as endocarditis

Marfan syndrome

Rheumatic heart disease

Many people with aortic regurgitation only require observation over time.

People with symptoms due to severe aortic valve regurgitation may benefit from certain blood pressure medicines called vasodilators. Other drug treatments for congestive heart failure, such as diuretics, can be helpful in severe aortic regurgitation.

When aortic regurgitation is severe, surgery is sometimes the recommended treatment. A surgeon will usually replace or repair the leaking aortic valve.

Causes of a leaky mitral valve include:

Some people with a leaky mitral valve don't require treatment. The standard approach is observation over time. Experts don't recommend daily medication for mitral regurgitation unless there is significant heart failure.

Surgery to repair or replace a mitral valve that is leaking severely can result in significant improvement for certain people. Because mitral regurgitation is slowly progressive, deciding when to operate -- neither too early, nor too late -- can be difficult.

Many healthy adults have a slightly leaky tricuspid valve. This may be discovered incidentally, usually causes no problems, and does not require treatment or follow-up.

Moderate or severe tricuspid regurgitation may result from pulmonary hypertension. Pulmonary hypertension is high blood pressure in the pulmonary artery. This high blood pressure has many possible causes. The main one is congestive heart failure.

Medicines may not be effective in treating tricuspid regurgitation. Diuretics, or water pills, can help relieve body swelling, or edema, that's due to congestive heart failure. The swelling is not always present, however.

The tricuspid valve may be repaired during surgery to correct other leaky heart valves. Surgical repair of the tricuspid valve generally works better than replacing it. Surgery to replace the tricuspid valve by itself (not along with the mitral or aortic valve) is only recommended in rare cases.

Like the tricuspid valve, a small amount of pulmonic regurgitation may be present in healthy people. There are rare cases when a leaky pulmonary valve causes problems. These may be due to:

Elevated blood pressure in the pulmonary artery (pulmonary hypertension)

Previous surgery as a child to repair a severe heart defect

Usually, no treatment is required for pulmonary regurgitation. Treating the underlying medical condition is the best approach.

Everyone with a leaky heart valve can benefit from daily exercise, like walking. Before engaging in competitive or contact sports, people with severe valve regurgitation should talk with their doctors.

Not smoking and maintaining a healthy weight are just as important for people with leaky heart valves as for other people. Regular follow-up with a doctor, even when there are no symptoms, can ensure a leaky heart valve does not cause problems that could be avoided.

Heart Valve Disease

Heart valve disease is when one or more of your heart valves don't work the way they should. Your heart has four valves: pulmonary, tricuspid, aortic, and mitral. Your heart valves open and close like doors as your heart beats to keep your blood flowing in the right direction.

About 2.5% of the population in the U.S. Has heart valve disease. It's more common in older adults.

Like one-way doors, your heart valves connect the chambers of your heart and blood vessels. They open and close with each heartbeat to keep your blood flowing in one direction, at the right time, through each chamber. 

Each valve is made up of strong flaps of tissue called leaflets or cusps. Healthy leaflets open and close fully and allow blood to flow through the opening. However, if any of your heart valves don't open or close fully, your blood might leak between chambers or not flow well through the opening.

Your four valves are:

Pulmonary valve. This connects your right ventricle and pulmonary artery. Your pulmonary artery is a branched vessel that leads to your lungs. When your right ventricle is full of blood, your heart squeezes (contracts), which opens the pulmonary valve and pushes the blood up and into your pulmonary artery. As it travels through the artery and veins in your lungs, it dumps the carbon dioxide it was carrying from your tissues and picks up oxygen to carry back. Your pulmonary veins then empty this oxygen-rich blood into your left atrium.

Mitral valve. This connects your left atrium and left ventricle. When your heart relaxes, your mitral valve opens and allows freshly oxygenated blood to flow from your left atrium into your left ventricle. It also keeps blood from flowing backwards from your left ventricle into your left atrium. When your left ventricle is full of blood, your heart contracts, which closes your mitral valve and, at the same time, opens your aortic valve.

Aortic valve. This connects your left ventricle to your aorta (pronounced ay-or-tuh). Your aorta is the biggest blood vessel in your body, and it carries oxygenated blood from your heart to the rest of your body. It also keeps blood from flowing backwards from your aorta into your left ventricle.

Tricuspid valve. This connects your right atrium and right ventricle. Blood that's full of carbon dioxide from your body tissues flows into your right atrium through two large veins called your superior vena cava (pronounced vay-nuh-kaa-vuh) and inferior vena cava. Your superior vena cava brings blood from your upper body tissues, and your inferior vena cava brings blood from your lower body tissues to the right atrium of your heart. When your heart is relaxed, your tricuspid valve is open, and blood flows into your right ventricle until it's full. Once it's full, your heart squeezes, which closes your tricuspid valve and, at the same time, opens your pulmonary valve. 

This pattern is repeated over and over with each heartbeat, which sends your blood continuously through your heart, lungs, and body.

There are three types of heart valve disease. The type you have depends on which of your valves has been affected and in what way. Sometimes, one of your valves has more than one problem or more than one of your valves has the same problem.

These are the problems that can affect any of your four heart valves:

Atresia (pronounced uh-TREE-zhuh). This is when one of your heart valves is missing. Since you have no opening between two of your heart's chambers, it can't do it's job of pumping blood continuously through your lungs and body. It's more common to be born with this condition, but you can develop it later, as well. The two main types are:

Pulmonary atresia, which affects your pulmonary valve. This blocks flow from your heart to your lungs through your pulmonary artery.

Tricuspid atresia, which affects your tricuspid valve. This blocks flow from your right atrium to your right ventricle.

Regurgitation. This is when one of your heart valves doesn't close tightly, so blood can leak backward through the opening. Therefore, not all your blood flows forward through the valve and your heart has to work harder to make up for the leaky valve. Less blood flows to the rest of your body. Your valves may not close tightly for a few different reasons, including that your valve is stretched, not the right size, or not the right shape. 

The most common reason for regurgitation is mitral valve prolapse. Prolapse is when one or both of the leaflets that make up your mitral valve flop or bulge backward. So the valve can't close completely. As with artesia, you may be born with this condition or develop it later. 

Stenosis. This is when one of your heart valves has an opening that's too narrow. It may be because the opening is too small or the leaflets that make up your valve didn't form correctly before you were born. One example is bicuspid aortic valve stenosis. This happens when your aortic valve forms with two leaflets instead of three. Your heart may have to work harder to pump blood through this narrowed opening. 

Heart valve disease can develop before birth (congenital) or sometimes over the course of your lifetime.

There are several causes of valvular heart disease including:

Congenital heart valve disease. This is a malformation that you are born with in one or more of your heart valves. 

Rheumatic disease. You may develop scars on your heart valves after a case of strep throat that wasn't treated with antibiotics. This is a very common cause of valve disease in the world, but it's not as common in the U.S. Because most strep infections are treated with antibiotics early in the infection. It's a more common cause in adults born in the U.S. Before 1943, when antibiotic use became more widespread.

Endocarditis. You may get an infection in the lining of your heart because of a serious infection in your blood. This infection can damage the leaflets that make up your heart valves. One cause of endocarditis is intravenous drug use.

Other types of heart disease, such as:

Heart failure, when your heart can't pump enough blood and oxygen to support your other organs.

Atherosclerosis of your aorta, when you have a buildup of fat, calcium, and cholesterol deposits on the inside of your aorta.

Aortic aneurym, when you have a ballooning where your aorta attaches to your heart.

High blood pressure.

Heart attack, which can damage the muscles that pen and close your heart valves.

Other conditions, such as:

Autoimmune diseases, such as lupus

Marfan syndrome, which is a connective tissue disease that can affect your heart valves.

Exposure to high-dose radiation, which may lead to calcium deposits on the valve.

The aging process, which can cause calcium deposits to develop on your heart valves, making them stiff or thickened and less efficient with age.

Age-related valve disease, such as calcification due to aging or slow degeneration over time.

Some congenital heart valve diseases run in families. 

You may develop heart valve disease as you age due to:

Family history. You can develop some heart valve problems because they run in your family. Also, a family history of early coronary heart disease can also raise your risk of developing a heart valve disease.

Lifestyle. Risk factors for other types of heart disease may also increase your risk for heart valve disease. Some of these risk factors include a lack of physical activity, unhealthy eating patterns, smoking, and obesity.

Medical devices. If you have a defibrillator or pacemaker, it can rub against a valve and create scar tissue or make your heart beat out of rhythm, which can stretch a heart valve. 

Other conditions, such as high blood pressure, diabetes, autoimmune disorders, and other heart conditions.

Radiation treatment for cancer. Radiation can thicken and narrow your heart valves.

Sex assigned at birth. People assigned male at birth (AMAB) are more likely than people assigned female at birth (AFAB) to get some heart valve conditions.

Your symptoms can vary depending on the type of heart valve disease you have.

Symptoms in adults.

You may not notice any symptoms, or you may mistake some of your symptoms for normal signs of aging. Your symptoms may also develop slowly. Your symptoms may not relate to the seriousness of your condition. You may have no symptoms at all and have severe valve disease, which needs prompt treatment. Or, as with mitral valve prolapse, you may have noticeable symptoms, yet tests may show the valve leak is not significant.

Symptoms of heart valve disease can include:

Breathing problems. This can include rapid breathing or shortness of breath. You may notice these symptoms most when you are exerting yourself, such as when you climb stairs or move fast. 

Dizziness or fainting. Sometimes, you may faint when you stand up.

Discomfort in your chest (angina). You may feel pressure, squeezing, tightness, or burning in your chest. It may spread to your shoulders, arms, neck, jaw, or back. It may also feel like an upset stomach.  This can happen when you are working hard or when you are resting. 

Feeling more tired than usual (fatigue).

Fever if you have an infection, such as myocarditis.

Palpitations. This may feel like a rapid heart rhythm, irregular heartbeat, skipped beats, or a flip-flop feeling in your chest.

Swelling around your eyes or in your ankles, feet, or abdomen. This is called edema. Swelling in your belly may cause you to feel bloated.

Rapid weight gain. A weight gain of 2 or 3 pounds in a day is possible.

Symptoms in newborns and young children.

Sometimes, your baby or child may have symptoms of a heart valve problem since birth. But sometimes, they may not appear until weeks or months after birth. These symptoms may be detected by your pediatrician during a newborn screening. These symptoms may include:

Not gaining weight or growing as they should. You may notice they have problems eating. If your child has trouble eating, call your doctor.

Blue skin tone, especially their lips, fingers, and toes. If you child has a blue skin tone, call 911 right away.

Low levels of oxygen.

Pale skin, rapid heartbeat, or cool, clammy hands. These are signs of shock. This is a medical emergency. Call 911 right away.

Weak pulse.

The stage depends on your symptoms, disease severity, the structure of the valve or valves, and blood flow through your heart and lungs. The American College of Cardiology and American Heart Association Joint Committee recommends the following stages:

Stage A (at risk). You have risk factors for heart valve disease

Stage B (progressive). You have mild or moderate valve disease, but you have no symptoms.

Stage C (severe, asymptomatic). You have severe valve disease, but you have no symptoms.

Stage D (severe, symptomatic). You have severe valve disease and you have symptoms.

Your heart doctor can tell if you have heart valve disease by:

Talking to you about your symptoms and medical history. Your doctor will ask about your risk factors and any related heart valve conditions that run in your family. 

Performing a physical exam. Your doctor will listen to the sounds your heart makes as your valves open and close. A murmur is a swishing sound made by blood flowing through a stenotic or leaky valve. Your doctor can also tell if your heart is enlarged or if your heart rhythm is irregular. They will also feel the strength of your pulse in your arm or neck. Also, your pediatrician may check your newborn's belly for signs of a swollen liver.

The doctor will listen to the lungs to hear if you are retaining fluid there, which shows the heart is not able to pump as well as it should.

Performing other tests, such as:

Echocardiography. This is the most common test to diagnose heart valve problems. It's a painless test that uses sound waves to make a video of your heart. It shows the size and shape of your heart and how well your heart is pumping blood. Your doctor can use Doppler ultrasound to see how well your blood flows through your heart's chambers and valve. It can find blood clots in you heart, fluid buildup in the sac around your heart, tumors, and problems with your arota. Echocardiography can also help your doctor find the cause of abnormal heart sounds, such as heart murmurs. 

EKG. An EKG records your heart's electrical activity through electrodes on your chest, arms, and legs. This can show how fast your heart is beating, if your heartbeat is steady or irregular, and the strength and timing of the electrical impulses passing through each part of your heart. 

Chest X-ray. This imaging test lets your doctor look at the structures in and around your chest. It can help diagnose and monitor conditions such as pneumonia, heart failure, lung cancer, tuberculosis, sarcoidosis, and lung tissue scars (fibrosis). Your doctor may also use X-ray to check for complications after some procedures and surgeries. Your doctor may also recommend cardiac catheterization before your chest X-ray. Cardiac catheterization uses dye to make your arteries show up more clearly on X-ray.

Stress test. This measures how healthy your heart is and how well it works during physical stress. You will usually do this by walking on a treadmill or riding on a stationary bike.

 

 

 

Heart valve disease treatment depends on the type of disease and how severe it is. Heart valve disease is a lifelong condition, and if you leave it untreated, it can lead to heart failure or other life-threatening conditions.

To begin with, your doctor may recommend you follow a healthy lifestyle and prescribe medicine to treat your symptoms. A healthy lifestyle includes:

Choose heart-healthy foods.

Take steps to reach and maintain a healthy weight.

Manage your stress.

Exercise regularly.

Quit smoking.

Medication

Medicines may ease your symptoms, prevent your heart valve disease from getting worse, or treat other heart problems that can affect your valves. Such medicines include:

High-blood pressure medicines such as diuretics (water pills) and vasodilators. Diuretics remove extra fluid from your tissues and bloodstream. They may reduce your symptoms of heart failure. Vasodilators (such as ACE inhibitors) reduce the amount of work your heart has to do to pump blood. They encourage your blood to flow forward rather than backward through a leaky valve.

Anti-arrhythmic medications such as beta-blockers. These help regulate your heart's rhythm.

Anticoagulants (blood thinners). These slow the rate at which your blood clots.

Antibiotics for infections that cause heart inflammation or to prevent rheumatic fever.

Prostaglandin for newborns to keep some pathways of the heart open and maintain blood flow.

Follow your doctor's orders when taking these heart disease drugs. Know the names of your medications, what they are for, and how often to take them. Keep a list in your wallet or purse with this information.

You may be able to stop taking some drugs after you have had heart valve surgery to correct the problem. You may need to take other medications all your life.

Heart valve repair

If you have new symptoms of heart valve disease or your symptoms get worse, your doctor may recommend heart valve repair surgery. Some surgeries can be done using minimally invasive techniques, which can reduce your blood loss, trauma, and how much time you spend recovering in the hospital after surgery. The most common procedures include:

Valvuloplasty, which is when your surgeon sews leaflets together, reshapes leaflets, patches a tear, reattaches loose leaflets, or splits apart leaflets that have fused. This could also be done using a balloon to stretch a valve opening.

Annuloplasty, which is when your surgeon tightens or strengthens the base of your heart valve to prevent sagging or leaking.

Stent placement. Stents are tubes placed into hollow structures in your body, such as heart vessels, to hold them open. This can allow blood flow or plug a leaky valve.

Implant a device. This is often done for people who have mitral valve regurgitation and can't have open heart surgery.

Remove obstructions such as calcium deposits, clumps of bacteria, or tumors.

Repair supporting structures. Your surgeon can replace or shorten the cords that support your valve and allow it to close completely.

Heart valve replacement

Sometimes, your heart valve can't be repaired, so it must be replaced. Your surgeon can replace your valve with a mechanical or biological heart valve. Which one of these is best for you depends on your age, risk factors, and other medical conditions.

Your valve may be replaced during open heart surgery or a minimally invasive procedure using a catheter. An example of a minimally invasive procedure is transcatheter aortic valve replacement or transcatheter aortic valve implantation. This may be used to treat aortic stenosis, for example.

Heart valve replacement pros and cons

Mechanical heart valves. The advantage to mechanical heart valves is their sturdiness. They are designed to last for many years. There are also drawbacks. Due to the artificial material involved, people who receive these valves will need to take lifelong blood thinner medication (anticoagulants) to prevent clots from forming in the mechanical valve. These clots can increase the risk for a stroke. Also, some people report a valve ticking sound that is usually not bothersome. It is the sound of the valve leaflets opening and closing.

Biological heart valves. The advantage of biological heart valves is that most people do not need to take lifelong blood thinners unless they have other conditions (such as atrial fibrillation) that warrant it. Biologic valves, traditionally, were not considered as durable as mechanical valves, especially in younger people. Previously available biologic valves usually needed to be replaced after about 10 years. However, some studies show that some biologic valves may last at least 17 years without decline in function. This represents a new milestone in the durability of biologic valves.

Homograft heart valves. Homografts are ideal heart valves for aortic valve replacement, especially when the aortic root is diseased or there is infection. The heart's natural anatomy is preserved and patients do not need to take lifelong blood thinners. However, the limited availability is a drawback in some settings.

Your doctors will work with you to decide which surgery and heart valve is right for you.

If heart valve disease is left untreated, you can get serious or life-threatening complications, such as the following conditions:

Acute respiratory distress syndrome. This is when fluid builds up in your air sacs and prevents your lungs from filling with air.

Irregular heartbeats or heart block, where there's a problem with the electrical system that controls your heart rate and rhythm.

Blood clots.

Blood infections such as septic shock.

Expanding, bulging, or tearing of your aorta.

Heart failure.

Infective endocarditis (heart inflammation).

Liver damage.

High blood pressure specifically in your lungs.

Stroke.

Heart attack.

Heart valve repair and replacement can improve your symptoms, but you may get complications from surgery, including:

Valve damage or leaks

Blood vessel injury or bleeding

Cardiac compression

Stroke

Blood clots

Injuries to your kidneys or the heart

When you have heart valve disease, it is important to protect yourself from future heart problems, even if your valve has been repaired or replaced with surgery. Here are some tips to stay healthy:

Don't smoke.

Manage your blood pressure and cholesterol.

Eat a heart-healthy diet that includes a lot of vegetables and fruit and is low in saturated and trans fat.

Exercise regularly.

Know the type and extent of your heart valve disease.

Tell all your doctors and dentist you have valve disease.

Call the doctor if you have symptoms of an infection.

Take good care of teeth and gums.

Take antibiotics before you undergo any procedure that may cause bleeding.

Carry a wallet card that you can get from the American Heart Association with specific antibiotic guidelines.

Take your medications. Your medicines control your symptoms and help your heart pump blood more efficiently. Follow your doctor's instructions about how and when to take your medicines.

See your heart doctor for regular visits, even if you have no symptoms. Follow up once a year or more often, depending on what your doctor says. 

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