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.

A candidate for transcatheter aortic valve replacement (TAVR) is typically someone with severe aortic stenosis, which is a narrowing of the aortic valve that restricts blood flow from the heart to the rest of the body.

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 located between the pumping chamber of the heart (left ventricle) and the left atrium, which is the chamber 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 prevents blood from being forced back into the lungs when the heart’s pumping chamber contracts.

The most common mitral valve disorder in the United States is mitral regurgitation, a condition in which the valve is leaky and allows blood to flow backward into the lungs when the main pumping chamber contracts. Mitral stenosis, a condition 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 based on the symptoms mentioned above or when your doctor detects a heart murmur. Your cardiologist will likely order an ultrasound of the heart, called an echocardiogram, which can definitively diagnose mitral regurgitation.

Medication does not slow the progression of mitral regurgitation. Your cardiologist will monitor the condition with echocardiograms to determine whether it is mild or moderate. In severe cases, open-heart surgery may be necessary. Valve repair is common, but in some cases, replacement may be required. Discuss your options with your surgeon, including minimally invasive techniques.

A non-surgical alternative is MitraClip, a procedure designed for patients who are not suitable candidates for surgery. It involves placing a clip on the valve through a vein in the groin.

A PFO (patent foramen ovale) is present in everyone at birth. When you are a fetus, there is no need for blood to be sent to the lungs because you receive all your oxygen from your mother’s blood. A flap between two heart chambers allows blood to bypass the lungs and return to the body. At birth, the pressures in the heart change rapidly, and this flap normally closes and scars over. However, in about 20% of people, the flap remains open, a condition known as a patent foramen ovale.

PFOs are not dangerous in most people and are usually detected incidentally during a heart ultrasound performed 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 for individuals in whom a stroke is believed to have occurred as a result of the PFO.

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

PFO closure should generally only be performed in individuals who have had a stroke thought to be related to the PFO and in whom an extensive search for other potential causes of the stroke has not identified any other source.

PFO closure is performed in the hospital. The device is implanted via the large vein in the groin, with an ultrasound camera in another large vein in the groin providing guidance. Most patients go home the same day, and the procedure is usually very well tolerated. It is performed under sedation. Patients will need to take aspirin and a second blood thinner for at least a month, followed by aspirin indefinitely.

Unlike PFOs, ASDs are quite rare. They are never considered normal and occur due to problems with the development of the heart, where 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 detected through an echocardiogram. If you are diagnosed with an ASD, your cardiologist will most likely order a transesophageal echocardiogram. This procedure is performed in the hospital under sedation and provides a much clearer view of the ASD and the wall between the atria.

Not every ASD needs to be closed. If the ASD is small, most people can be monitored with routine echocardiograms to evaluate for any worsening heart issues. However, if blood flow through the ASD appears to be affecting the right side of the heart, closure of the ASD is recommended.

ASD closure is performed either through open-heart surgery or via the large vein in the groin. Many patients can be treated without open-heart surgery, but the approach depends largely on the shape, size, and location of the ASD within the wall between the atria. You should discuss with your cardiologist whether surgery or a minimally invasive procedure is the best option for you.