From the Guidelines
Aortic stenosis patients should undergo transcatheter aortic valve implantation (TAVI) as a viable alternative to surgical valve replacement (SAVR), regardless of surgical risk, as demonstrated by recent randomized clinical trials 1.
Diagnosis and Treatment
Aortic stenosis is a heart valve condition where the aortic valve narrows, restricting blood flow from the heart to the body. It typically develops gradually, with symptoms appearing when the narrowing becomes severe, including:
- Chest pain
- Shortness of breath
- Fatigue
- Fainting The condition is often caused by age-related calcium buildup, congenital heart defects, or rheumatic fever. Diagnosis involves physical examination, listening for a characteristic heart murmur, and confirming with tests like echocardiography, cardiac catheterization, or CT scans.
Management
Treatment depends on severity - mild cases require monitoring, while severe cases typically need valve replacement. TAVI has been shown to be a viable alternative to SAVR, with recent studies demonstrating its effectiveness regardless of surgical risk 1. Medications like beta-blockers or diuretics may help manage symptoms but don't fix the valve itself. Without treatment, severe aortic stenosis can lead to heart failure, stroke, or sudden cardiac death, making proper medical evaluation essential for anyone experiencing symptoms.
Considerations
In patients with severe aortic stenosis, the risk of noncardiac surgery is significant, with a mortality risk of approximately 10% if the patient is not a candidate for valve replacement 1. Therefore, it is crucial to carefully evaluate the patient's condition and consider the risks and benefits of surgery. Percutaneous balloon aortic valvuloplasty may be a reasonable alternative as a bridge to surgery in hemodynamically unstable patients 1.
From the Research
Definition and Causes of Aortic Stenosis
- Aortic stenosis refers to significant narrowing of the aortic valve, which can be caused by calcific disease, congenital causes, or rheumatic valvular disease 2.
- Calcific aortic stenosis is the most frequent expression of aortic valve disease in the Western world, with an increasing prevalence as the population ages 3.
Symptoms and Diagnosis
- Symptoms of advanced aortic stenosis include angina, dyspnea, and syncope, with patients having these symptoms having a much higher mortality rate than asymptomatic patients 2.
- Initial evaluation should include an electrocardiogram, complete blood count, basic metabolic profile, coagulation studies, troponin, brain natriuretic peptide, type and screen, and a chest radiograph 2.
- Transthoracic echocardiogram is the test of choice for diagnosing aortic stenosis, but point-of-care ultrasound has been found to have good accuracy when a formal echocardiogram is not feasible 2.
Treatment and Management
- The treatment of choice for aortic stenosis is valve replacement, but extracorporeal membrane oxygenation and percutaneous balloon dilatation of the aortic valve have been described as temporizing measures 2.
- Transcatheter aortic valve replacement (TAVR) has become the preferred treatment option in appropriate patients with symptomatic severe aortic stenosis, with advancements expanding the eligible population to include bicuspid aortic valve with feasible anatomy, small aortic annuli, low-flow, low-gradient AS, and younger patients 4.
- Balloon aortic valvuloplasty (BAV) remains an option for temporary palliation and symptomatic relief in patients with prohibitive comorbidities or other high-risk features, and can serve as a bridge to either surgical or transcatheter aortic valve replacement 3.
- Early intervention in asymptomatic severe aortic stenosis has been shown to reduce rates of major adverse cardiovascular events, driven primarily by reductions in unplanned hospitalizations 5.
Contemporary Research and Guidelines
- There is a growing interest in applying TAVR in patients with less than severe aortic stenosis, with several randomized control trials investigating medical therapy to reduce or prevent the progression of AS 6.
- Guidelines for the management of asymptomatic severe aortic stenosis vary, with consensus found for intervention thresholds including left ventricular dysfunction and very severe AS, but discrepancies existing in the utility of biomarkers, myocardial fibrosis, exercise stress testing, and choice of intervention 5.