Two years ago I was diagnosed with a leaky heart valve. I was prescribed 75mg clopidogrel and at the time, this worked. Now, at the grand old age of 83, although I’m still taking long walks and maintaining my large garden, my breathing is laboured and pushing my lightweight mower is an ordeal. I wondered if surgery was available — would a pacemaker be beneficial?
Blanche Thomas, Pontnewydd, Torfaen
The news that you have a leaking heart valve must have caused you some anxiety and I don’t suppose the word ‘leaky’ helped. The usual medical term for leaking heart valves is ‘incompetent’, ‘insufficient’, or ‘regurgitating’ — the key is the severity.
The heart is a double pump — the right and left sides work together to push blood around the body.
The right side receives deoxygenated blood returning from the body via the right atrium (the upper chamber); when this contracts it pushes the blood into the lower chamber, the right ventricle. When the ventricle contracts, this deoxygenated blood is pumped into the lungs, where carbon dioxide is removed and it’s replenished with oxygen.
Heart facts: There are four valves in the heart, but it’s the two on the left side — the mitral and aortic valves — that are most commonly damaged or affected by disease
This freshly oxygenated blood is then received back into the left side of the heart, which is the larger, stronger side, via the left atrium. When the atrium contracts, the blood passes into the left ventricle, the main pumping chamber that sends blood around the body.
The role of the valves is to help keep the blood flowing forward — they are essentially flaps that open in only one direction as the blood flows through.
There are four valves in the heart, but it’s the two on the left side — the mitral and aortic valves — that are most commonly damaged or affected by disease, causing leakage (this is not surprising as there’s much more pressure on the left).
The mitral valve sits between the left atrium and left ventricle. The aortic valve is the outlet valve of the left ventricle, leading to the aorta, the main artery out of the heart. When the left ventricle contracts to send blood around the body, the mitral valve closes to prevent blood flowing backwards into the atrium — at the same time the aortic valve is open so the blood is pumped into the aorta. When the heart relaxes to fill, the aortic valve closes, preventing blood flowing backwards from the aorta into the heart.
Damage to the valves can occur for a number of reasons, including rheumatic fever (an immune system reaction following a throat infection that can trigger inflammation of the heart valves) and infective endocarditis (an infection of the heart valves caused by bacteria). The aortic valve can also become stretched — and leaky — if the aorta develops an aneurysm, where the artery wall swells or ‘balloons’.
I suspect your doctor’s diagnosis was based on listening to your heart and hearing a murmur. This is the sound made when a valve is damaged or diseased and is not able to close and seal, allowing blood to pass backwards.
We can tell which valve is involved from the site and nature of the sound. Typically the patient will also experience breathlessness as the heart is pumping less efficiently. Other symptoms can include pain or palpitations, but there can be problems with a valve for years without symptoms.
Risk: Damage to the valves can occur for a number of reasons, including rheumatic fever and infective endocarditis (an infection of the heart valves caused by bacteria)
Your doctor may have referred you for an electrocardiogram to record the electrical activity of the heart — this might give a clue about possible causes such as an abnormal heart rhythm, the most common being atrial fibrillation, which frequently accompanies valve abnormality.
You may also have had an echocardiogram (ultrasound) to confirm which valve is incompetent and to what extent. Once it’s been diagnosed, the condition of the valve should be monitored periodically — including echocardiography every year or two — so judgments can be made about treatment.
Atrial fibrillation brings a risk of blood pooling in the left atrium and causing a clot. To prevent this your doctor has prescribed an anticoagulant — clopidogrel. This drug is not a treatment for leaky valve as such, so won’t have had any effect on breathlessness.
Surgery to replace or repair a valve is a major operation, so is only appropriate when the condition is severe.
At the age of 83, although this is feasible, it will only be recommended when absolutely essential. Pacemakers send an electrical impulse to trigger a heartbeat, and are used for patients where the natural pacemaking mechanisms of the heart have become faulty. This is not the issue with a leaking heart valve so unless you also have a heartbeat problem, a pacemaker will offer no benefit.
Our daughter has had a burning tongue for months — it also has red patches on it. Her GP has no answer. Can you enlighten us?
D. Peverill, by email.
What you’ve described is characteristic of a condition known as idiopathic burning mouth syndrome — essentially it’s a diagnosis of exclusion, that is, where other conditions such as herpes simplex have been ruled out, and where there is burning pain on the tongue or the lining of the mouth that has occurred daily, for at least three months.
It is most common in middle-aged women, and up to 50 per cent of cases resolve spontaneously. What triggers it is not clear, but it’s thought to be the result of problems with the sensory nerve fibres of the mouth and tongue.
The standard treatment is a low dose of a tricyclic antidepressant for a period of four to six weeks, which can help with the burning sensation, although dryness of the mouth is a potential side-effect.
However, with idiopathic burning mouth syndrome the tongue looks normal and the red patches you describe slightly flies in the face of that diagnosis.
My suggestion is that the problem may be one of three alternative diagnoses. First, atrophic glossitis, which is an inflammation of the tongue — it appears smooth, shiny, and red. It is caused by nutritional deficiency such as a lack of iron or vitamin B12.
Another possible cause is contact allergy of the tongue, caused by an allergy to dental materials, rubber latex, or to some foods such as cinnamon. However this condition is quite rare. The third possibility is that it’s geographic tongue, which causes red patches. Usually there’s no discomfort, although on occasion, some patients do experience a burning sensation.
My suggestion is that your daughter discusses the use of a tricyclic with her GP and if atrophic glossitis is suspected, she has a blood test for iron and vitamin B12 deficiency.
IN MY OPINION….GUT BACTERIA IS THE FUTURE
Our understanding of our gut bacteria — the microbiome — continues to grow in leaps and bounds. The latest revelations that caught my eye concern the relationship between these bacteria and the central nervous system: it seems our gut bacteria may have a profound effect on the brain, both positive and negative.
For instance, recent animal studies have suggested a link between the microbiome and anxiety and depression. Another very exciting area of research is Alzheimer’s disease. Research published late last year in Nature found that patients with dementia had less diverse gut bacteria.
A note of caution, however, because what’s not clear is whether this is cause or effect. So we cannot say that taking probiotics (good bacteria) in supplement form will have any impact on brain health.
But I’ve no doubt that there is going to be ever greater focus on food as medicine. And on what we allow into our bodies, from drugs to environmental chemicals — not least because of their potential impact on our microbiome. Our guts are set to play the key role in the next health revolution.