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Aortic Valvular Stenosis

para>Note: If the aortic valve area is >1.5 cm2 and the gradient is <15 mm Hg, there is no benefit from AVR.

  • Transcatheter aortic valve replacement (TAVR) offers a less invasive option for some patients (6).For those who are high at surgical risk and considered inoperable, TAVR has demonstrated superiority to medical therapy.For those who are high at surgical risk, TAVR has demonstrated noninferiority to surgical AVR (6).For those who are intermediate at surgical risk, TAVR may emerge as a reasonable alternative to surgical risk, though this indication has not yet been approved in the United States.Valve-in-valve TAVR can be considered in high-risk patients with failed surgically implanted bioprosthetic valves.
  • Percutaneous balloon valvuloplasty may have role in palliation or as a bridge to valve replacement in hemodynamically unstable or high-risk patients (5)[C] but is not recommended as an alternative to valve replacement.

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

  • Advise patients to immediately report symptoms referable to AS.
  • Asymptomatic patients: yearly history and physical (5)[C]
  • Serial ECHO: yearly for severe AS, every 1 to 2 years for moderate AS, every 3 to 5 years for mild AS (5)[B]

PATIENT EDUCATION

Physical activity limitations

  • Asymptomatic mild AS: no restrictions
  • Asymptomatic moderate to severe AS: Avoid strenuous exercise. Consider exercise stress test prior to starting exercise program.

PROGNOSIS

  • 25% mortality/year in symptomatic patients who do not undergo valve replacement; average survival is 2 to 3 years without AVR surgery.
  • Median survival in symptomatic AS (3): heart failure: 2 years; syncope: 3 years; angina: 5 years
  • Perisurgical mortality: AVR surgery has 4% mortality rate; AVR + CABG has 6.8% mortality rate
  • Adverse postoperative prognostic factors: age, heart failure (HF) New York Heart Association (NYHA) class III/IV, cerebrovascular disease, renal dysfunction, CAD

REFERENCES

11 Carabello BA, Paulus WJ. Aortic stenosis. Lancet. 2009;373(9667):956-966.22 Otto CM. Calcific aortic stenosis-time to look more closely at the valve. N Engl J Med. 2008;359(13):1395-1398.33 Grimard BH, Larson JM. Aortic stenosis: diagnosis and treatment. Am Fam Physician. 2008;78(6):717-724.44 Nishimura RA, Otto CM, Bonow RO, et al. 2014 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. J Thorac Cardiovasc Surg. 2014;148(1):e1-e132.55 Bonow RO, Carabello BA, Kanu C, et al. ACC/AHA 2006 guidelines 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 (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation. 2006;114(5):e84-e231.66 Smith CR, Leon MB, Mack MJ, et al. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364(23):2187-2198.

CODES

ICD10

  • I35.0 Nonrheumatic aortic (valve) stenosis
  • I06.0 Rheumatic aortic stenosis
  • Q23.0 Congenital stenosis of aortic valve

ICD9

  • 424.1 Aortic valve disorders
  • 395.0 Rheumatic aortic stenosis
  • 746.3 Congenital stenosis of aortic valve

SNOMED

  • 60573004 Aortic valve stenosis (disorder)
  • 72011007 Rheumatic aortic stenosis (disorder)
  • 18546004 Congenital stenosis of aortic valve (disorder)
  • 194987006 aortic valve stenosis with insufficiency (disorder)
  • 194984004 Aortic stenosis, non-rheumatic (disorder)

CLINICAL PEARLS

  • AS is diagnosed on physical exam by a systolic crescendo-decrescendo murmur and delayed and diminished pulses.
  • Symptomatic AS most commonly presents as angina, syncope, and heart failure.
  • Symptomatic AS has a very poor prognosis, unless treated with surgical intervention.