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.