Pathophysiology
- Stenosis: Valve leaflets become thickened, stiffened, or calcified, reducing the effective orifice area. The chamber upstream of the stenotic valve must generate greater pressure to push blood through the narrowed opening. This pressure overload causes concentric hypertrophy (wall thickening) of the upstream chamber. Initially compensatory, the hypertrophy eventually leads to diastolic dysfunction, chamber dilation, and heart failure. Aortic stenosis forces the left ventricle to hypertrophy. Mitral stenosis increases left atrial pressure, causing pulmonary congestion and eventually right heart failure.
- Regurgitation (insufficiency): Valve leaflets fail to coapt (close completely), allowing a fraction of each stroke volume to flow backward. The receiving chamber experiences volume overload, causing eccentric hypertrophy (chamber dilation). Chronic volume overload eventually exhausts the chamber's compensatory reserve, leading to heart failure. Mitral regurgitation causes left atrial dilation (promoting AFib) and pulmonary congestion. Aortic regurgitation causes left ventricular dilation and a characteristic wide pulse pressure (high systolic, low diastolic).
- Mitral valve prolapse (MVP): One or both mitral leaflets are redundant (myxomatous degeneration) and bulge (prolapse) into the left atrium during systole. The vast majority of cases are benign — a mid-systolic click may be the only finding. In a minority, prolapse is severe enough to produce regurgitation, which can progress over years to clinically significant volume overload.
- Rheumatic heart disease: An autoimmune consequence of untreated Group A streptococcal pharyngitis. Molecular mimicry between streptococcal antigens and cardiac valve tissue triggers an immune attack on the valves, producing inflammation, scarring, and eventual stenosis (most commonly mitral stenosis). Still a leading cause of valve disease worldwide, though uncommon in Canada.
- Compensated versus decompensated disease: Valve disease may be hemodynamically significant for years while the heart compensates through hypertrophy and increased contractility. During this compensated phase, the client may be asymptomatic or only symptomatic with heavy exertion. Decompensation occurs when the heart can no longer maintain adequate cardiac output — producing dyspnea at rest, peripheral edema, fatigue, and arrhythmias.
Signs and Symptoms
- Heart murmur — the hallmark finding. Caused by turbulent flow through the dysfunctional valve. Identified on auscultation (not MT scope, but frequently reported in client history).
- Dyspnea — exertional initially, then at rest as the condition decompensates. Orthopnea (dyspnea when lying flat) indicates pulmonary congestion
- Fatigue and exercise intolerance — reduced cardiac output limits oxygen delivery
- Palpitations — particularly from AFib, which frequently accompanies mitral valve disease (atrial dilation promotes AFib)
- Syncope or presyncope on exertion — characteristic of severe aortic stenosis. A critical red flag indicating that cardiac output cannot increase to meet demand
- Chest pain — from associated coronary disease or severe aortic stenosis with subendocardial ischemia
- Peripheral edema — bilateral ankle swelling from right-sided failure or severe left-sided decompensation
Red Flags
- Syncope on exertion in a client with known valve disease (especially aortic stenosis) — indicates critical stenosis with risk of sudden death. Urgent medical referral
- New-onset dyspnea at rest, paroxysmal nocturnal dyspnea, or rapid-onset peripheral edema — signs of acute decompensation. Medical referral before further treatment
- New-onset irregular pulse in a valve disease client — likely AFib with associated stroke risk. Refer for anticoagulation evaluation
- Fever with known valve disease or prosthetic valve — may indicate infective endocarditis. Urgent medical referral
Massage Therapy Considerations
- MVP without regurgitation or symptoms: Massage is not contraindicated. MVP alone is the most common valve finding in the general population. The client may report awareness of palpitations during relaxation. Reassure and adjust stimulation level if needed.
- Stable, medically managed valve disease: Massage is indicated with modifications — lighter pressure, slow repositioning, and monitoring for dizziness or dyspnea during treatment.
- Decompensated disease: Massage is contraindicated until the condition is medically stabilized. Dyspnea at rest, significant peripheral edema, or recent hospitalization for heart failure indicate decompensation.
- Anticoagulant awareness: Clients with AFib secondary to valve disease, or those with prosthetic mechanical valves, are on anticoagulants (warfarin for mechanical valves; DOACs for AFib). Reduce pressure to prevent bruising. Avoid deep friction and cupping.
- Prosthetic valve clients: These clients are medically complex. Consult their cardiologist regarding manual therapy restrictions. Do not assume standard treatment is safe without clearance.
- Avoid stimulating techniques: Rapid rocking, vigorous percussion, and techniques that significantly increase heart rate may worsen arrhythmias or increase cardiac demand in a heart with limited reserve.
- Positioning: Semi-reclined or side-lying for clients with orthopnea or pulmonary congestion. Elevate the head at least 30–45 degrees if the client cannot lie flat.
- AFib overlap: Atrial fibrillation frequently accompanies mitral and aortic valve disease. Apply all AFib modifications concurrently (see arrhythmias).
CMTO Exam Relevance
- Category A7 — Systemic Conditions (Cardiovascular)
- Distinguish stenosis (pressure overload, concentric hypertrophy) from regurgitation (volume overload, eccentric hypertrophy) — these are different hemodynamic problems with different clinical presentations
- MVP alone (without regurgitation) is not a contraindication — this is a commonly tested distinction
- Syncope on exertion in aortic stenosis is a critical red flag — one of the most testable emergency recognition scenarios in valve disease
- Rheumatic heart disease (molecular mimicry from untreated strep) remains the most common cause of acquired valve disease worldwide
- Anticoagulation is required for mechanical prosthetic valves (warfarin) and for AFib secondary to valve disease — pressure modification is mandatory
Key Takeaways
- Heart valve disease involves stenosis (restricted forward flow) or regurgitation (backward flow), with mitral and aortic valves most clinically significant
- MVP without regurgitation is benign and does not contraindicate massage. It is the most common valve finding in the general population
- Syncope on exertion in a client with valve disease (especially aortic stenosis) is a critical red flag requiring urgent medical referral
- Decompensated valve disease (dyspnea at rest, significant edema) contraindicates massage until medically stabilized
- Anticoagulant use is common — always ask about blood-thinning medications and reduce pressure accordingly
- AFib frequently accompanies valve disease. Apply AFib modifications (pulse check, anticoagulant awareness, no carotid sinus pressure) concurrently
- Rheumatic heart disease from untreated streptococcal pharyngitis remains a globally significant cause of acquired valve disease