From the Guidelines
Aortic stenosis and aortic aneurysm are distinct conditions that can coexist but do not have a direct causal relationship, with management prioritizing the more immediately life-threatening condition, usually severe aortic stenosis, followed by aneurysm repair if needed, as per the 2022 ACC/AHA guideline 1.
Conditions Overview
Aortic stenosis involves narrowing of the aortic valve opening, restricting blood flow from the heart to the body, while an aortic aneurysm is an abnormal bulging or dilation of the aortic wall that can occur in any section of the aorta. These conditions share some risk factors including age, hypertension, and atherosclerosis, which explains why they sometimes occur together in the same patient, as highlighted in the 2014 ESC guidelines on the diagnosis and treatment of aortic diseases 1.
Relationship and Management
The hemodynamic changes from aortic stenosis, particularly increased pressure gradients across the valve, can theoretically contribute to aortic wall stress, but this isn't considered a primary cause of aneurysm formation. When both conditions coexist, management becomes more complex, often requiring careful timing of interventions. The goal is to reduce the risk of adverse aortic events, such as aortic dissection, rupture, and aortic-related death, by determining the optimal timing of intervention based on a careful anatomic assessment and weighing the risk of future adverse aortic events against the risk of intervention, as outlined in the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1.
Key Considerations
- Regular imaging surveillance is essential for patients with either condition to monitor progression and determine optimal timing for intervention.
- The presence of aortic aneurysm may be associated with other locations of aneurysms, emphasizing the importance of a full assessment of the aorta and the aortic valve in patients with aortic aneurysms, both at baseline and during follow-up, as noted in the 2014 ESC guidelines 1.
- Patients with aortic aneurysm are at increased risk of cardiovascular events, mostly unrelated to the aneurysm but plausibly related to common risk factors and pathways, as well as the increased risk of cardiovascular comorbidities at the time of aneurysm diagnosis.
From the Research
Relationship Between Aortic Stenosis and Aortic Aneurysm
- The treatment of patients with severe aortic stenosis (SAS) who concomitantly present with abdominal aortic aneurysm (AAA) is not well-defined 2.
- Aortic valve replacement surgery, performed alone, increases the risk of AAA rupture 2.
- Simultaneous transcatheter aortic valve implantation and endovascular aneurysm repair for SAS and symptomatic AAA is a safe alternative, especially in high-risk patients 2, 3, 4.
- The combined procedure with transcatheter aortic valve implantation (TAVI) followed by endovascular aortic aneurysm repair (EVAR) seems to be feasible, safe, and effective 3, 4.
- Detailed preoperative planning and a carefully tailored management strategy by a multidisciplinary team are essential for the combined procedure 3, 4.
Treatment Options
- Transcatheter aortic valve replacement (TAVR) and EVAR can be performed simultaneously in patients with SAS and AAA 2, 3, 4.
- Surgical valve replacement is the standard of care for patients at low to moderate surgical risk, while TAVR may be considered in patients at high or prohibitive surgical risk 5.
- Medical management of concurrent hypertension, atrial fibrillation, and coronary artery disease will lead to optimal outcomes 5.
Patient Management
- Patients with concomitant SAS and AAA require careful management, including detailed preoperative planning and a multidisciplinary team approach 2, 3, 4.
- Serial Doppler echocardiography is recommended for asymptomatic patients with SAS, and cardiology referral is recommended for all patients with symptomatic moderate and severe SAS 5.