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AORTIC STENOSIS
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ESSENTIALS OF DIAGNOSIS
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Congenital bicuspid aortic valve, usually asymptomatic until middle or old age Degenerative or calcific aortic stenosis; same risk factors as atherosclerosis Symptoms likely once the peak echo gradient is > 64 mm Hg Echocardiography/Doppler is diagnostic Surgery indicated for symptoms Surgical risk is typically low even in the very elderly Surgery considered for asymptomatic patients with severe aortic stenosis
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There are two common clinical scenarios in which aortic stenosis is prevalent The first is due to a congenitally abnormal unicuspid or bicuspid valve, rather than tricuspid Symptoms at times occur in young or adolescent individuals if severe, but more often symptoms emerge at age 50 65 years when calcification and degeneration of the valve becomes manifest A dilated ascending aorta, primarily due to an intrinsic defect in the aortic media, may accompany the bicuspid valve Coarctation of the aorta is also seen in a small number of patients with aortic stenosis A second group develops what has traditionally been called degenerative or calcific aortic stenosis, which is thought to be related to calcium deposition due to processes similar to what occurs in atherosclerotic vascular disease Approximately 25% of patients over age 65 years and 35% of those over age 70 years have echocardiographic evidence of aortic sclerosis About 10 20% of these will progress to hemodynamically significant aortic stenosis over a period of 10 15 years Thus, aortic stenosis has become the most common surgical valve lesion in developed countries, and many patients are elderly The risk factors for aortic stenosis in the elderly are similar to those for atherosclerosis, including hypertension, hypercholesterolemia, and smoking Hypertrophic obstructive cardiomyopathy may also coexist with valvular aortic stenosis
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The clinical assessment of the severity of aortic stenosis may be difficult, especially when there is reduced cardiac output or significant associated aortic regurgitation The ECG reveals LVH or suggestive repolarization changes in most patients, but can be normal in up to 10% The chest radiograph may show a normal or enlarged cardiac silhouette, calcification of the aortic valve, and dilation and calcification of the ascending aorta The echocardiogram provides useful data about aortic valve calcification and opening and LV thickness and function, while Doppler can provide an excellent estimate of the aortic valve gradient The peak Doppler gradient is derived by squaring the maximal flow velocity through the valve orifice and multiplying times 4; thus, a 4 m/s maximum velocity gradient translates into a 64 mm Hg peak Doppler gradient Valve
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area estimation by echocardiography is less reliable Cardiac catheterization mostly provides an assessment of the hemodynamic consequence of the aortic stenosis, and a look at the coronary arteries In younger patients, and in patients with high aortic gradients the aortic valve need not be crossed at catheterization If it is crossed, the valve gradient can be measured at catheterization and an estimated valve area calculated; a valve area below 10 cm2 indicates significant stenosis in the newest ACC/AHA guidelines Aortic regurgitation can be semiquantified by aortic root angiography In patients with a low EF and both low output and a low valve gradient, it may be unclear if an increased afterload is responsible for the low EF or if there is an associated cardiomyopathy To sort this out, the patient should be studied at baseline and then during an intervention that increases cardiac output (eg, dobutamine or nitroprusside infusion) If the valve area increases, the flow-limiting problem is not the valve, but rather the cardiomyopathy, and surgery is not warranted If the valve area remains unchanged at the higher outputs, then the valve is considered flow limiting and surgery is indicated
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Prognosis & Treatment
Following the onset of heart failure, angina, or syncope, the prognosis without surgery is poor (50% 3-year mortality rate) Medical treatment may stabilize patients in heart failure, but surgery is indicated for all symptomatic patients with evidence of significant aortic stenosis Valve replacement is usually not indicated in asymptomatic individuals, though a class II indication is to operate once the peak valve gradient by Doppler exceeds 64 mm Hg or the mean exceeds 40 mm Hg The surgical mortality rate for valve replacement is low, even in the elderly, and ranges from 2% to 5% This low risk is due to the dramatic hemodynamic improvement that occurs with relief of the increased afterload Mortality rates are substantially higher when there is an associated ischemic cardiomyopathy Severe coronary lesions are usually bypassed at the same time The interventional options in patients with aortic stenosis are variable and dependent on the patient s lifestyle and age In the young and adolescent patient, percutaneous valvuloplasty still has a role Balloon valvuloplasty is less effective and is associated with early restenosis in the elderly, and thus is rarely used Data suggest aortic balloon valvuloplasty has an advantage only in those with preserved LV function, and such patients are usually excellent candidates for surgical aortic valve replacement (AVR) There is continuing interest in using the Ross procedure in younger patients The Ross procedure is performed by moving the patient s own pulmonary valve to the aortic position and replacing the pulmonary valve with a homograft (or rarely a bioprosthetic valve) However, dilation of the pulmonary valve autograft and consequent aortic regurgitation, plus early stenosis of the pulmonary homograft in the pulmonary position, has reduced the enthusiasm for this approach in some institutions Middle-aged adults generally can take the anticoagulation necessary for the use of mechanical AVR, so most undergo AVR with a bileaflet mechanical valve If the aortic
root is severely dilated as well (> 55 cm), then the valve may be housed in a Dacron sheath (Bentall procedure) and the root replaced as well Alternatively, a human homograft root and valve replacement may be used In the elderly, bioprosthetic (either porcine or bovine pericardial) valves with a life expectancy of about 10 15 years are routinely used to avoid need for anticoagulation Recent data favor the bovine over the porcine pericardial valve If the aortic annulus is small, a bioprosthetic valve with a short sheath can be sewn to the aortic wall (the stentless AVR) rather than sewing the prosthetic annulus to the aortic annulus Anticoagulation is required with the use of mechanical valves, and the international normalized ratio (INR) should be maintained between 20 and 25 Mechanical aortic valves are less subject to thrombosis than mechanical mitral valves There is growing interest in developing a percutaneous approach to AVR Both a retrograde approach (from the aorta) and an antegrade approach (from the ventricles by way of a transseptal catheter across the atrial septum) are being investigated The devices being tested use either a stent with a trileaflet bovine pericardial valve constructed in it, or a stent with a large valve from a cow s jugular vein mounted inside Preliminary data are encouraging
Carabello B Clinical practice Aortic stenosis N Engl J Med 2002 Feb 28;346(9):677 82 [PMID: 11870246] Otto C Valvular aortic stenosis: disease severity and timing of intervention J Am Coll Cardiol 2006 Jun 6;47(11):2141 51 [PMID: 16750677] Pereira JJ et al Survival after aortic valve replacement for severe aortic stenosis with low transvalvular gradients and severe left ventricular dysfunction J Am Coll Cardiol 2002 Apr 17;39 (8):1356 63 [PMID: 11955855]
AORTIC REGURGITATION (CHRONIC REGURGITATION)
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