Aortic stenosis general approach
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Diagnosis |
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Treatment |
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Percutaneous Aortic Balloon Valvotomy (PABV) or Aortic Valvuloplasty |
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Transcatheter Aortic Valve Replacement (TAVR) |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]; Rim Halaby
Overview
Once a patient with aortic stenosis becomes symptomatic, aortic valve replacement should be performed as long as the patient can tolerate surgery and has no co-morbidities. If severe left ventricular dysfunction is present in the setting of aortic stenosis, it is of utmost importance to differentiate between true severe aortic stenosis and pseudo-severe aortic stenosis as these two entities have different pathophysiologies and different outcomes after aortic valve replacement. Medical therapy reduces symptoms but does not prolong life. If a patient has extensive co-morbidities, transcatheter aortic valve implantation can be considered. Aortic valvuloplasty can be considered in those patients who are too sick for surgery or transcatheter aortic valve implantation.[1]
General Approach
- The normal aortic valve has an orifice area of 4 cm2. Aortic stenosis is a progressive pathology that becomes usually symptomatic when the area decreases to 1 cm2. Once symptomatic, the most effective treatment for aortic stenosis is aortic valve replacement. Almost all symptomatic patients should undergo aortic valve replacement. One important exception is in the case of severe aortic stenosis with ventricle dysfunction where extensive testing should be done to differentiate between true severe aortic stenosis and pseudo-severe aortic stenosis. Patients with true severe low flow low gradient aortic stenosis benefit from aortic valve replacement, whereas patients with pseudo-severe low flow low gradient aortic stenosis might not benefit from aortic valve replacement and have higher operative mortality.
- Asymptomatic patients should be followed up yearly for any new onset of symptoms. No treatment has been proven to delay the progression of aortic stenosis. Follow up with an echocardiography should be done every 1, 3, 5 years in severe, moderate and mild aortic stenosis respectively.
- Patients undergoing aortic valve replacement and having co-existing multi-vessel coronary artery disease should have concomitantly CABG.[2]
Shown below is an algorithm summarizing the management of symptomatic and asymptomatic patients with aortic stenosis and the indications for AVR. If the patient does not meet any of the decision pathways in the algorithm, regular monitoring is recommended and AVR is not indicated.[2][3]
Abbreviations: AVR: Aortic valve replacement; LVEF: Left ventricular ejection fraction; ΔPmean: mean pressure gradient; Vmax: maximum velocity
| Abnormal aortic valve AND Reduction in systolic opening | |||||||||||||||||||||||||||||||||||||||||||||||||||
| Severe aortic stenosis: Vmax≥4m/s AND ΔPmean≥40 mmHg | Vmax3-3.9 m/s AND ΔPmean20-39 mmHg | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Is the patient symptomatic? | Is the patient symptomatic? | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Yes (Stage D1) | No (Stage C) | Yes | No (Stage B) | ||||||||||||||||||||||||||||||||||||||||||||||||
| LVEF <50% (Stage C2) | Is LVEF <50%? | The patient is undergoing another cardiac surgery | |||||||||||||||||||||||||||||||||||||||||||||||||
| The patient is undergoing another cardiac surgery | Yes | No | |||||||||||||||||||||||||||||||||||||||||||||||||
| Vmax≥5m/s AND ΔPmean≥60 mmHg (Very severe stage C1) AND Low surgical risk | Dobutamine stress echocardiography: Aortic valve area ≤1 cm2 AND Vmax≥4 ms (Stage D2) | Aortic valve area ≤1 cm2 AND LVEF ≥50% (Stage D3) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Abnormal exercise treadmill test | The symptoms are likely the result of the aortic stenosis | ||||||||||||||||||||||||||||||||||||||||||||||||||
| ΔVmax>0.3 m/s/y AND Low surgical risk | |||||||||||||||||||||||||||||||||||||||||||||||||||
| AVR (Class I) | AVR (Class IIa) | AVR (Class IIb) | AVR (Class IIa) | AVR (Class IIa) | AVR (Class IIa) | ||||||||||||||||||||||||||||||||||||||||||||||
Shown below is an algorithm summarizing the approach to patients with low flow, low gradient aortic stenosis.[4]
Abbreviations: AVR: Aortic valve replacement; EOA: Effective orifice area; ΔPmean: mean pressure gradient
| Ultrasound evaluation of aortic stenosis Effective orifice area (EOA)≤ 1 cm2 Pressure gradient (ΔP)<40 mmHg | |||||||||||||||||||||||
| Low grade low flow aortic stenosis | |||||||||||||||||||||||
| Normal left ventricular ejection fraction | Left ventricular ejection fraction≤ 40-50%[3] | ||||||||||||||||||||||
| No specific recommendations: - Surgical AVR, or - Transcather AVR, or - Medical treatment | |||||||||||||||||||||||
| Dobutamine stress test | |||||||||||||||||||||||
| Increase in stroke volume by ≥ 20% | Increase in stroke volume by <20% | ||||||||||||||||||||||
| Presence of left ventricular flow reserve | Absence of left ventricular flow reserve | ||||||||||||||||||||||
| ΔP≥40 EOA<1-1.2 | ΔP<40 EOA≥1-1.2 | EOA<1-1.2 | |||||||||||||||||||||
| True severe aortic stenosis | Pseudo-severe aortic stenosis | True severe aortic stenosis | |||||||||||||||||||||
| Surgical AVR with/without CABG | Medical treatment Close follow up | Transcather AVR | |||||||||||||||||||||
Available Therapeutic Options
- Aortic stenosis surgery via aortic valve replacement
- Transcatheter aortic valve implantation
- Percutaneous aortic balloon valvotomy (PABV) or aortic valvuloplasty
- Medical management
References
- ↑ Franck Levy, Marcel Laurent, Jean Luc Monin, Jean Michel Maillet, Agnes Pasquet, Thierry Le Tourneau, Helene Petit-Eisenmann, Mauro Gori, Yannick Jobic, Fabrice Bauer, Christophe Chauvel, Alain Leguerrier & Christophe Tribouilloy (2008). "Aortic valve replacement for low-flow/low-gradient aortic stenosis operative risk stratification and long-term outcome: a European multicenter study". Journal of the American College of Cardiology. 51 (15): 1466–1472. doi:10.1016/j.jacc.2007.10.067. PMID 18402902. Unknown parameter
|month=ignored (help) - ↑ 2.0 2.1 Bonow RO, Carabello B, de Leon AC, Edmunds LH, Fedderly BJ, Freed MD; et al. (1998). "ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease. Executive Summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease)". J Heart Valve Dis. 7 (6): 672–707. PMID 9870202.
- ↑ 3.0 3.1 Nishimura, R. A.; Otto, C. M.; Bonow, R. O.; Carabello, B. A.; Erwin, J. P.; Guyton, R. A.; O'Gara, P. T.; Ruiz, C. E.; Skubas, N. J.; Sorajja, P.; Sundt, T. M.; Thomas, J. D. (2014). "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". Circulation. doi:10.1161/CIR.0000000000000031. ISSN 0009-7322.
- ↑ Pibarot P, Dumesnil JG (2012). "Low-flow, low-gradient aortic stenosis with normal and depressed left ventricular ejection fraction". J Am Coll Cardiol. 60 (19): 1845–53. doi:10.1016/j.jacc.2012.06.051. PMID 23062546.