Aortic Stenosis: Diagnosis

Chapter

Abstract

The diagnosis of aortic stenosis (AS) is reached through clinical and instrumental assessment of patients [1]. The symptomatic forms are characterized by angina, dyspnea, and syncope, but the diagnostic suspicion can be supported by the presence of typical physical signs, such as harsh diamond-shaped systolic murmur, often matched by a more intense fremitus along the right upper sternal margin and irradiated to the neck, parvus et tardus pulse, fourth sound, and attenuation or disappearance of the aortic component of the second sound. A complete picture of heart failure can be found where a systolic murmur is often faint or lacking. In asymptomatic forms, physical findings can be the only evidence of aortic valve (AV) disease. With regard to instrumental examinations, standard electrocardiogram (ECG) can highlight signs of left ventricular hypertrophy. However, even in the more severe forms of AS, ECG may not show any alteration.

References

  1. 1.
    Dalla Volta S, Daliento L, Rozzolini R. Malattie del cuore e dei vasi (terza edizione). Libri Italia SRL: Mc Graw-Hill; 2005.Google Scholar
  2. 2.
    Baumgartner H, Hung J, Bermejo J, et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. Eur J Echocardiogr. 2009;10:1–25.CrossRefPubMedGoogle Scholar
  3. 3.
    Chambers BJ. Aortic stenosis. Eur J Echocardiogr. 2009;10:11–9.CrossRefGoogle Scholar
  4. 4.
    Saikrishnan N, Kumar G, Sawaya FJ, et al. Accurate assessment of aortic stenosis: a review of diagnostic modalities and hemodynamics. Circulation. 2014;129:244–53.CrossRefPubMedGoogle Scholar
  5. 5.
    Nishimura R, Otto C, Bonow R, et al. AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:e521–643.CrossRefPubMedGoogle Scholar
  6. 6.
    Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease: the joint task force on the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg. 2012;42:S1–S44.CrossRefPubMedGoogle Scholar
  7. 7.
    Bach DS. Echo/Doppler evaluation of hemodynamics after aortic valve replacement: principles of interrogation and evaluation of high gradients. JACC Cardiovasc Imaging. 2010;3(3):296–304.CrossRefPubMedGoogle Scholar
  8. 8.
    Hachicha Z, Dumesnil J, Bogaty P, et al. Paradoxical low-flow, low-gradient severe aortic stenosis despite preserved ejection fraction is associated with higher afterload and reduced survival. Circulation. 2007;115:2856–64.CrossRefPubMedGoogle Scholar
  9. 9.
    Dumesnil J, Pibarot P, Carabello B. Paradoxical low flow and/or low gradient severe aortic stenosis despite preserved left ventricular ejection fraction: implication for diagnosis and treatment. Eur Heart J. 2010;31:281–9.CrossRefPubMedGoogle Scholar
  10. 10.
    Awtry E, Davidoff R. Low-flow/low—gradient aortic stenosis. Circulation. 2011;124:739–41.CrossRefGoogle Scholar
  11. 11.
    Lancellotti P. Grading aortic stenosis severity when the flow modifies the gradient-valve area correlation. Cardiovasc Diagn Ther. 2012;2(1):6–9.PubMedPubMedCentralGoogle Scholar
  12. 12.
    Jander N, Minners J, Holme I, et al. Outcome of patients with low-gradient “severe” aortic stenosis and preserved ejection fraction. Circulation. 2011;123(8):887–95.CrossRefPubMedGoogle Scholar
  13. 13.
    Dayan V, Vignolo G, Magne J, et al. Outcome and impact of aortic valve replacement in patients with preserved LVEF and low-gradient aortic stenosis. J Am Coll Cardiol. 2015;66(23):2594–603.CrossRefPubMedGoogle Scholar
  14. 14.
    Clavel M, Berthelot-Richer M, Le Ven F, et al. Impact of classic and paradoxical low flow on survival after aortic valve replacement for severe aortic stenosis. J Am Coll Cardiol. 2015;65(7):645–53.CrossRefPubMedGoogle Scholar
  15. 15.
    De Filippi CR, DuWayne LW, Brickner ME, et al. Usefulness of Dobutamine echocardiography in distinguishing severe from nonsevere valvular aortic stenosis in patients with depressed left ventricular function and low transvalvular gradients. J Am Cardiol. 1995;75:192–4.Google Scholar
  16. 16.
    Dahou A, Bartko P, Capoulade R, et al. Usefulness of global left ventricular longitudinal strain for risk stratification in low ejection fraction, low-gradient aortic stenosis. Circ Cardiovasc Imaging. 2015;8(3):e002117.CrossRefPubMedGoogle Scholar
  17. 17.
    Ge S, Warner JB Jr, Abraham TP, et al. Three-dimensional surface area of the aortic valve orifice by three dimensional echocardiography: clinical validation of a novel index for assessment of aortic stenosis. Am Heart J. 1998;136:1042–50.CrossRefPubMedGoogle Scholar
  18. 18.
    Poh K, Levine RA, Solis J, et al. Assessing aortic valve area in aortic stenosis by continuity equation: a novel approach using real-time three- dimensional echocardiography. Eur Heart J. 2008;29:2526–35.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Gutierrez-Chico JL, Zamorano JL, Prieto-Moriche E, et al. Real-time three-dimensional echocardiography in aortic stenosis: a novel, simple, and reliable method to improve accuracy in area calculation. Eur Heart J. 2008;29:1296–306.CrossRefPubMedGoogle Scholar
  20. 20.
    Ng AC, Delgado V, Van der KF, et al. Comparison of aortic root dimension and geometries before and after transcatheter aortic valve implantation by 2- and 3-dimensional transesophageal echocardiography and multislice computed tomography. Circ Cardiovasc Imaging. 2010;3:94–102.CrossRefPubMedGoogle Scholar
  21. 21.
    Das P, Rimington H, Chambers J. Exercise testing to stratify risk in aortic stenosis. Eur Heart J. 2005;26:1309–13.CrossRefPubMedGoogle Scholar
  22. 22.
    Dhoble A, Sarano ME, Kopcky SL, et al. Safety of symptom-limited cardiopulmonary exercise testing in patients with aortic stenosis. Am J Med. 2012;125(7):704–8.CrossRefPubMedGoogle Scholar
  23. 23.
    Maréchaux S, Hachicha Z, Bellouin A. Usefulness of exercise-stress echocardiography for risk stratification of true asymptomatic patients with aortic valve stenosis. Eur Heart J. 2010;31(11):1390–7.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Lancellotti P, Lebois F, Simon M, et al. Prognostic importance of quantitative exercise Doppler echocardiography in asymptomatic valvular aortic stenosis. Circulation. 2005;112:I377–82.PubMedGoogle Scholar
  25. 25.
    Lancellotti P, Magne J, Donal E, et al. Determinants and prognostic significance of exercise pulmonary hypertension in asymptomatic severe aortic stenosis. Circulation. 2012;26:851–9.CrossRefGoogle Scholar
  26. 26.
    Cueff C, Serfaty J, Cimadevilla C, et al. Measurement of aortic valve calcification using multislice computed tomography: correlation with haemodynamic severity of aortic stenosis and clinical implication for patients with low ejection fraction. Heart. 2010;2011(97):721–6.Google Scholar
  27. 27.
    Clavel M, Messika-Zeitoun D, Pibarot P, et al. The complex nature of discordant severe calcified aortic valve disease grading: new insights from combined Doppler ecocardiographic and computed tomographic study. JACC. 2013;62:2329–38.CrossRefPubMedGoogle Scholar
  28. 28.
    Aggarwal SR, Clavel M, Messika-Zeitoun D, et al. Sex differences in aortic valve calcification measured by multidetector computed tomography in aortic stenosis. Circ Cardiovasc Imaging. 2013;6:40–7.CrossRefPubMedGoogle Scholar
  29. 29.
    Clavel M, Pibarot P, Messika-Zeitoun D, et al. Impact of aortic valve calcification, as measured by MDCT, on survival in patients with aortic stenosis. J Am Coll Cardiol. 2014;64(12):1202–13.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Clavel M, Pibarot P. Assessment of low-flow, low-gradient aortic stenosis: multimodality imaging is the key to success. EuroIntervention. 2014;10:U52–60.CrossRefPubMedGoogle Scholar
  31. 31.
    Clavel M, Malouf J, Messika-Zeitoun D, et al. Aortic valve area calculation in aortic stenosis by CT and Doppler echocardiography. JACC Cardiovasc Imaging. 2015;8:248–57.CrossRefPubMedGoogle Scholar
  32. 32.
    Chin CW, Khaw HJ, Luo E, et al. Echocardiography underestimates stroke volume and aortic valve area: implications for patients with small-area low-gradient aortic stenosis. Can J Cardiol. 2014;30(9):1064–72.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Clavel M, Dusmesnil JG, Pibarot P, et al. Discordant grading of aortic stenosis using echocardiography and what it means: new insights from magnetic resonance imaging. Can J Cardiol. 2014;30:959–61.CrossRefPubMedGoogle Scholar
  34. 34.
    Wong S, Spina R, Toemoe S, et al. Is cardiac magnetic resonance imaging as accurate as echocardiography in the assessment of aortic valve stenosis? Interact Cardiovasc Thorac Surg. 2016;22:480–6.CrossRefPubMedGoogle Scholar
  35. 35.
    Dweck MR, Joshi S, Murigu T, et al. Midwall fibrosis is an independent predictor of mortality in patients with aortic stenosis. J Am Coll Cardiol. 2011;58:1271–9.CrossRefPubMedGoogle Scholar
  36. 36.
    Barone-Rochette G, Pièrard S, De Meester de Ravestein C, et al. Prognostic significance of LGE by CMR in aortic stenosis patients undergoing valve replacement. J Am Coll Cardiol. 2014;58:1271–9.Google Scholar
  37. 37.
    Nishimura RA, Carabello BA. Hemodynamics in the cardiac catheterization laboratory of the 21st century. Circulation. 2012;125:2138–50.CrossRefPubMedGoogle Scholar
  38. 38.
    Grossman & Baim’s Cardiac Catheterization. Angiography and intervention. 8th ed. Philadelphia: Lippincott Williams and Wilkins; 2013.Google Scholar
  39. 39.
    Hakki AH. A simplified valve formula for the calculation of stenotic valve areas. Circulation. 1981;63:1050–5.CrossRefPubMedGoogle Scholar
  40. 40.
    Otto CM, Burwash IG, Legget ME, et al. Prospective study of asymptomatic valvular aortic stenosis. Clinical, echocardiographic, and exercise predictors of outcome. Circulation. 1997;95:2262–70.CrossRefPubMedGoogle Scholar
  41. 41.
    Lund O, Nielsen TT, Emmertsen K, et al. Mortality and worsening of prognostic profile during waiting time for valve replacement in aortic stenosis. Thorac Cardiovasc Surg. 1996;44:289–95.CrossRefPubMedGoogle Scholar
  42. 42.
    Rosenhek R, Binder T, Porenta G, et al. Predictors of outcome in severe, asymptomatic aortic stenosis. N Engl J Med. 2000;343:611–7.CrossRefPubMedGoogle Scholar
  43. 43.
    Pellikka PA, Sarano ME, Nishimura RA, et al. Outcome of 622 adults with asymptomatic, hemodynamically significant aortic stenosis during prolonged follow-up. Circulation. 2005;111:3290–5.CrossRefPubMedGoogle Scholar
  44. 44.
    Taniguchi T, Morimoto T, Shiomi H, et al., CURRENT AS Registry Investigators. Initial surgical versus conservative strategies in patients with asymptomatic severe aortic stenosis. J Am Coll Cardiol. 2015;66:2827–38.Google Scholar
  45. 45.
    Pellikka PA. Observation for mildly symptomatic normal-flow, low-gradient severe aortic stenosis: caution advised. Heart. 2015;101:1349–50.CrossRefPubMedGoogle Scholar
  46. 46.
    Généreux P, Stone GW, O’Gara PT, et al. Natural history, diagnostic approaches and therapeutic strategies for patients with asymptomatic severe aortic stenosis. J Am Coll Cardiol. 2016;67:2263–88.CrossRefPubMedGoogle Scholar
  47. 47.
    Monin JL, Quere JP, Monchi M, et al. Low gradient aortic stenosis: operative risk stratification and predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics. Circulation. 2003;108:319–24.CrossRefPubMedGoogle Scholar
  48. 48.
    Levy F, Laurent M, Monin JL, et al. Aortic valve replacement for low-flow/low-gradient aortic stenosis: operative risk stratification and long-term outcome: a European multicenter study. J Am Coll Cardiol. 2008;51:1466–72.CrossRefPubMedGoogle Scholar
  49. 49.
    Tribouilloy C, Lévy F, Rusinaru D, et al. Outcome after aortic valve replacement for low-flow/low-gradient aortic stenosis without contractile reserve on dobutamine stress echocardiography. J Am Coll Cardiol. 2009;53:1865–73.CrossRefPubMedGoogle Scholar
  50. 50.
    Pibarot P, Dumesnil J. Low-flow, low- gradient aortic stenosis with normal and depress left ventricular ejection fraction. Am J Cardiol. 2012;60(19):1845–53.CrossRefGoogle Scholar
  51. 51.
    Brown ML, Pellikka PA, Schaff HV, et al. The benefits of early valve replacement in asymptomatic patients with severe aortic stenosis. J Thorac Cardiovasc Surg. 2008;135:308–15.CrossRefPubMedGoogle Scholar
  52. 52.
    Monin J, Lancellotti P, Monchi M, et al. Risk score for predicting outcome in patients with asymptomatic aortic stenosis. Circulation. 2009;120:69–75.CrossRefPubMedGoogle Scholar
  53. 53.
    Lancellotti P, Donal E, Magne J, et al. Risk stratification in asymptomatic moderate to severe aortic stenosis: the importance of the valvular, arterial and ventricular interplay. Heart. 2010;96:1364–71.CrossRefPubMedGoogle Scholar
  54. 54.
    Eleid MF, Pellikka PA. Asymptomatic severe aortic stenosis: what are we waiting for? J Am Coll Cardiol. 2015;66:2842–3.CrossRefPubMedGoogle Scholar
  55. 55.
    Bonow RO. Asymptomatic aortic stenosis: it is not simple anymore. J Am Coll Cardiol. 2015;66:2839–41.CrossRefPubMedGoogle Scholar
  56. 56.
    Pai RG, Kapoor N, Bansal RC, et al. Malignant natural history of asymptomatic severe aortic stenosis: benefit of aortic valve replacement. Ann Thorac Surg. 2006;82:2116–22.CrossRefPubMedGoogle Scholar
  57. 57.
    Kang DH, Park SJ, Rim JH, et al. Early surgery versus conventional treatment in asymptomatic very severe aortic stenosis. Circulation. 2010;121:1502–9.CrossRefPubMedGoogle Scholar
  58. 58.
    Lancellotti P, Magne J, Donal E, et al. Clinical outcome in asymptomatic severe aortic stenosis: insights from the new proposed aortic stenosis grading classification. J Am Coll Cardiol. 2012;59:235–43.CrossRefPubMedGoogle Scholar
  59. 59.
    Kamath AR, Pai RG. Risk factors for progression of calcific aortic stenosis and potential therapeutic targets. Int J Angiol. 2008;17:63–70.CrossRefPubMedPubMedCentralGoogle Scholar
  60. 60.
    Rosenhek R, Zilberszac R, Schemper M, et al. Natural history of very severe aortic stenosis. Circulation. 2010;121:151–6.CrossRefPubMedGoogle Scholar
  61. 61.
    Kitai T, Honda S, Okada Y, et al. Clinical outcomes in non-surgically managed patients with very severe versus severe aortic stenosis. Heart. 2011;97:2029–32.CrossRefPubMedGoogle Scholar
  62. 62.
    Cioffi G, Faggiano P, Vizzardi E, et al. Prognostic value of inappropriately high left ventricular mass in asymptomatic severe aortic stenosis. Heart. 2011;97:301–7.CrossRefPubMedGoogle Scholar
  63. 63.
    Nessmith MG, Fukuta H, Brucks S, et al. Usefulness of an elevated B-type natriuretic peptide in predicting survival in patients with aortic stenosis treated without surgery. Am J Cardiol. 2005;96(10):1445–8.CrossRefPubMedGoogle Scholar
  64. 64.
    Clavel MA, Malouf J, Michelena HI, et al. B type natriuretic peptide clinical activation in aortic stenosis: impact on long-term survival. J Am Coll Cardiol. 2014;63:2016–25.CrossRefPubMedGoogle Scholar
  65. 65.
    Capoulade R, Magne J, Dulgheru R, et al. Prognostic value of plasma B-type natriuretic peptide levels after exercise in patients with severe asymptomatic aortic stenosis. Heart. 2014;100(20):1606–12.CrossRefPubMedGoogle Scholar
  66. 66.
    Banovic M, Brkovic V, Vujisic-Tesic B, et al. Valvulo-arterial impedance is the best mortality predictor in asymptomatic aortic stenosis patients. J Heart Valve Dis. 2015;24:156–63.PubMedGoogle Scholar
  67. 67.
    Lancellotti P, Donal E, Magne J, et al. Impact of global left ventricular afterload on left ventricular function in asymptomatic severe aortic stenosis: a two-dimensional speckle-tracking study. Eur J Echocardiogr. 2010;11:537–43.CrossRefPubMedGoogle Scholar
  68. 68.
    Yingchoncharoen T, Gibby C, Rodriguez L, et al. Association of myocardial deformation with outcome in asymptomatic aortic stenosis with normal ejection fraction. Circ Cardiovasc Imaging. 2012;5:719–25.CrossRefPubMedGoogle Scholar
  69. 69.
    Nagata Y, Takeuchi M, Wu VC, et al. Prognostic value of LV deformation parameters using 2D and 3D speckle-tracking echocardiography in asymptomatic patients with severe aortic stenosis and preserved LV ejection fraction. J Am Coll Cardiol Img. 2015;8:235–45.CrossRefGoogle Scholar
  70. 70.
    Astor BC, Kaczmarek RG, Hefflin B, et al. Mortality after aortic valve replacement: results from a nationally representative database. Ann Thorac Surg. 2000;70:1939–45.CrossRefPubMedGoogle Scholar
  71. 71.
    Culliford AT, Galloway AC, Colvin SB, et al. Aortic valve replacement for aortic stenosis in persons aged 80 years and over. Am J Cardiol. 1991;67:1256–60.CrossRefPubMedGoogle Scholar
  72. 72.
    Shroyer AL, Coombs LP, Peterson E, et al. The society of thoracic surgeons: 30-day operative mortality and morbidity risk models. Ann Thorac Surg. 2003;75:1856–65.CrossRefPubMedGoogle Scholar
  73. 73.
    Roques F, Nashef SA, Michel P, et al., Euro SCORE Study Group. Risk factors for early mortality after valve surgery in Europe in the 1990s: lessons from the Euro SCORE Pilot Program. J Heart Valve Dis. 2001;10:572–77.Google Scholar
  74. 74.
  75. 75.
    Rosenhek R, Iung B, Tornos P, et al. ESC Working Group on Valvular Heart Disease Position Paper: assessing the risk of interventions in patients with valvular heart disease. Eur Heart J. 2012;33(7):822–8.CrossRefPubMedGoogle Scholar
  76. 76.
    Iung B, Laouénan C, Himbert D, et al. Predictive factors of early mortality after transcatheter aortic valve implantation: individual risk assessment using a simple score. Heart. 2014;14:1142–3.Google Scholar
  77. 77.
    Capodanno D, Barbanti M, Tamburino C, et al; OBSERVANT Research Group. A simple risk tool (the OBSERVANT score) for prediction of 30-day mortality after transcatheter aortic valve replacement. Am J Cardiol. 2014;113:1851–8.Google Scholar
  78. 78.
    Hermiller JB, Yakubov SJ, Reardon MJ, et al. Predicting early and late mortality after transcatheter aortic valve replacement. J Am Coll Cardiol. 2016;68(4):343–52.CrossRefPubMedGoogle Scholar
  79. 79.
    Iung B, Baron G, Butchart EG, et al. A prospective survey of patients with valvular heart disease in Europe: the Euro Heart Survey on Valvular Disease. Eur Heart J. 2003;24:1231–43.CrossRefPubMedGoogle Scholar

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© Springer International Publishing AG 2018

Authors and Affiliations

  1. 1.General Surgery and Medical-Surgery SpecialitiesUniversity of CataniaCataniaItaly

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