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Aortic Stenosis

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Clinical Cases in Cardiology

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Abstract

Valvular aortic stenosis (AS) is the second most prevalent adult valve disease in the USA. Prevalence increases with age, and severe AS, if left untreated, is fatal a few years from symptom onset. Obstruction may be valvular, subvalvular, or supravalvular. AS represents a continuum disease: (1) an increase in afterload, (2) a decrease in systemic and coronary blood flow from obstruction, and (3) progressive hypertrophy. These mechanisms result in the classic symptom triad of dyspnea, angina, and syncope. Transthoracic echocardiography is the gold standard modality for initial diagnosis and subsequent evaluation of aortic stenosis. The main hemodynamic parameters recommended for clinical evaluation of AS severity with transthoracic echocardiography are AS jet velocity, mean transaortic gradient, and valve area by continuity equation. Low-flow, low-gradient aortic stenosis with low LVEF is characterized by the combination of aortic valve effective orifice area (EOA) <1.0 cm2 or <0.6 cm2/m2 when indexed for body surface area, low mean transvalvular gradient (i.e., <40 mmHg), and low LVEF (<40 %), causing an LF state. Early valve replacement should be recommended in all patients with severe aortic stenosis and symptoms. Transcatheter aortic valve implantation (TAVI) is the treatment of choice in patients with severe aortic valve stenosis who are not candidates for surgery. In patients who will be undergoing surgery or TAVI, balloon valvuloplasty may be considered as a bridge to these types of intervention. Every 6 months asymptomatic severe AS should be reevaluated. Patients should be reevaluated yearly if there is mild and moderate AS with significant calcification. Follow-up visits should include echocardiography with attention on hemodynamic progression, LV function and hypertrophy, and the ascending aorta.

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Authors and Affiliations

  1. Clinica di Cardiologia e Aritmologia, Università Politecnica delle Marche, Via Conca, 71, Ancona, 60126, Italy

    Lorena Scappini, Simone Maffei & Alessio Menditto

Authors
  1. Lorena Scappini
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  2. Simone Maffei
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  3. Alessio Menditto
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Corresponding author

Correspondence to Lorena Scappini .

Editor information

Editors and Affiliations

  1. Cardiology Clinic, Università Politecnica delle Marche Ospedali Riuniti Ancona, Ancona, Italy

    Alessandro Capucci

Appendix

Appendix

1.1 Indications for Aortic Valve Replacement in Aortic Stenosis [22]

Class I, Level B

  • AVR is indicated in patients with severe AS and any symptoms related to AS.

Class I, Level C

  • AVR is indicated in asymptomatic patients with severe AS and abnormal exercise test showing symptoms on exercise clearly related to AS.

  • AVR is indicated in patients with severe AS undergoing CABG and surgery of the ascending aorta or another valve.

  • AVR is indicated in asymptomatic patients with severe AS and systolic LV dysfunction (LVEF <50 %) not due to another cause.

Class IIa, Level B

  • AVR should be considered in high-risk patients with severe symptomatic AS who are suitable for TAVI, but in whom surgery is favored by a “heart team” based on the individual risk profile and anatomic suitability.

  • AVR should be considered in asymptomatic patients with severe AS and abnormal exercise test showing fall in blood pressure below baseline.

  • AVR should be considered in patients with moderate AS undergoing CABG and surgery of the ascending aorta or another valve.

  • AVR should be considered in symptomatic patients with low-flow, low-gradient (<40 mmHg) AS with normal EF only after careful confirmation of severe AS.

  • AVR should be considered in symptomatic patients with severe AS; low-flow, low-gradient with reduced EF; and evidence of flow reserve.

  • AVR should be considered in asymptomatic patients, with normal EF and none of the abovementioned exercise test abnormalities, if the surgical risk is low, and one or more of the following findings are present:

    • Very severe AS defined by a peak transvalvular velocity >5.5 m/s

    • Severe valve calcification and a rate of peak transvalvular velocity progression ≥0.3 m/s per year

Class IIB, Level C

  • AVR may be considered in symptomatic patients with severe AS low-flow, low-gradient, and LV dysfunction without flow reserve.

  • AVR may be considered in asymptomatic patients with severe AS, normal EF, and none of the abovementioned exercise test abnormalities, if surgical risk is low, and one or more of the following findings are present:

    • Markedly elevated natriuretic peptide levels confirmed by repeated measurements and without other explanations

    • Increase of mean pressure gradient with exercise by >20 mmHg

    • Excessive LV hypertrophy in the absence of hypertension

1.2 Recommendations for the Use of Transcatheter Aortic Valve Implantation [22]

Class I, Level C

  • TAVI should only be undertaken with a multidisciplinary “heart team” including cardiologists and cardiac surgeons and other specialists if necessary.

  • TAVI should only be performed in hospitals with cardiac surgery on-site.

Class I, Level B

  • TAVI is indicated in patients with severe symptomatic AS who are not suitable for AVR as assessed by a “heart team” and who are likely to gain improvement in their quality of life and to have a life expectancy of more than 1 year after consideration of their comorbidities.

Class IIa, Level B

  • TAVI should be considered in high-risk patients with severe symptomatic AS who may still be suitable for surgery, but in whom TAVI is favored by a “heart team” based on the individual risk profile and anatomic suitability.

1.3 Contraindications for Transcatheter Aortic Valve Implantation [22]

  • Absolute contraindications: Estimated life expectancy <1 year, improvement of quality of life by TAVI unlikely because of comorbidities, inadequate annulus size (<18 mm, >29 mm), thrombus in the left ventricle, active endocarditis, plaques with mobile thrombi in the ascending aorta or aortic arch, and inadequate vascular access (vessel size, calcification, tortuosity).

  • Relative contraindications: Bicuspid or noncalcified valves, untreated coronary artery disease requiring revascularization, and LVEF <20 % hemodynamic instability.

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Scappini, L., Maffei, S., Menditto, A. (2015). Aortic Stenosis. In: Capucci, A. (eds) Clinical Cases in Cardiology. Springer, Cham. https://doi.org/10.1007/978-3-319-19926-9_15

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  • DOI: https://doi.org/10.1007/978-3-319-19926-9_15

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-19925-2

  • Online ISBN: 978-3-319-19926-9

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