Aortic stenosis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Overview

Aortic stenosis is the progressive narrowing of the diameter of the aortic valve (normal valve area is 3 - 4 cm²) and symptoms are caused by a decrease in stroke volume that leads to decrease perfusion, however, symptoms normally appear when the stenosis is ≤ 1.0 cm².

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Management

Shown below is an algorithm summarizing the approach to aortic stenosis [1][2]


Abbreviations: LVH: Left ventricle hypertrophy; CXR: Chest x-ray; ECG: Electrocardiogram; LBBB: Left bundle branch block; AF: Atrial fibrillation; AVR: Aortic valve replacement; VHD: Valve heart disease; TAVR: Transcatheter aortic valve replacement

 
 
 
 
Characterize the symptoms:
❑ Most patients are asymptomatic
Dyspnea on exertion
❑ Exertional dizziness
❑ Exertional angina
Syncope
Chest pain
Palpitations
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inquire about past medical history:
❑ Previously healthy
Cardiac disease:
Hypertension
Bicuspid aortic valve
Rheumatic fever
Pulmonary disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

❑ Heart rate
❑ Pulses

Pulsus parvus et tardus

❑ Cardiac palpation

Apical impulse (due to LVH)
Systolic thrill

❑ Cardiac auscultation

❑ Crescendo-decrescendo systolic ejection murmur with ejection click
❑ Best heard at the upper right sternal border
❑ Bilateral radiation to the carotid arteries
❑ Murmur increases with: squatting, expiration
❑ Murmur decreases with valsalva maneuver

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❑ Pulmonary auscultation: search for rales (seen when congestive heart failure has developed)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order imaging and adjuvant studies:
❑ Order an echocardiography, assess:
❑ Valve morphology
❑ Pressure gradient
Aortic valve area
Ejection fraction
❑ LV wall thickness and motility

❑ Order a CXR, look for:

Cardiomegaly
Valve calcification
❑ Dilatation of ascending aorta
Pulmonary congestion

❑ Order a ECG, look for:

LVH
❑ Left atrium enlargement
LBBB
AF (in late disease)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Interpret results from echo
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No stenosis (Stage A)
❑ Valve area 2.5-3.5 cm²
❑ No pressure gradient
 
Mild to moderate stenosis (Stage B)
Mild:
❑ Valve area 1.5-2.5 cm²
❑ Pressure gradient ≤ 25 mmHg
Moderate:
❑ Valve area 1.0-1.5 cm²
❑ Pressure gradient 25-40 mmHg
 
 
 
 
 
Severe stenosis
❑ Valve area ≤ 1.0 cm²
❑ Pressure gradient ≥ 40 mmHg
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Normal valve
Bicuspid valve
Sclerotic valve
 
Perform a periodic echocardiogram (Class I; Level of Evidence: B)
❑ Every 3 -5 yrs for mild stenosis
❑ Every 1 - 2 yrs for moderate stenosis
 
 
 
Patient asymptomatic
(Stage C)
 
 
 
 
Patient symptomatic
(Stage D)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Control hypertension (Class I; Level of Evidence: B)
 
If patient undergoes another cardiac surgery:
Schedule for AVR (Class IIa; Level of Evidence: C)
 
Normal LVEF
(Stage C1)
 
LVEF < 50%
(Stage C2)
 
High gradient (ΔP ≥ 40 mmHg)
(Stage D1)
 
Low gradient (ΔP ≤ 40 mmHg)
❑ Normal LVEF (Stage D2)
❑ LVEF < 50% (Stage D3)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform a periodic echocardiogram every 6 - 12 months (Class I; Level of Evidence: B)
 
 
Schedule for AVR (Class I; Level of Evidence: A)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If aortic velocity ≥ 5 m/s or decrease in exercise tolerance:
Schedule for AVR (Class IIa; Level of Evidence: B)
 
 
 
 
 
 
 
 
 
 
 
 
 

Choice of Intervention

Shown below is an algorithm summarizing the choice of the intervention to aortic stenosis [1]
STS: Society of Thoracic Surgeons

 
 
 
 
 
 
Patient scheduled for AVR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High risk[3]
❑ STS Score[4] > 10
❑ EuroScore[5] > 20
 
 
 
 
 
Low to moderate risk[3]
❑ STS Score[4] < 10
❑ EuroScore[5] < 20
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ A multidisciplinary group of physicians with expertise in VHD, cardiac imaging, interventional cardiology, cardiac anesthesia, and cardiac surgery should decide intervention (Surgical AVR or
TAVR) (Class I; Level of Evidence: C)
❑ Schedule for TAVR (Class IIa; Level of Evidence: B)[1] [6]
 
 
 
 
 
❑ Schedule for surgical AVR (Class I; Level of Evidence: A)
 
 
 
 


Type of Valve and Discharge Anticoagulation Therapy

 
 
 
 
 
 
Determine the age of the patient
Check for contraindications for anticoagulation
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Patients ≤ 70 years old (Class IIa; Level of Evidence: B), and
❑ No contraindication for anticoagulation
 
 
 
 
 
❑ Patients ≥ 70 years old (Class IIa; Level of Evidence: B), or
❑ Patients with anticoagulant therapy contraindications (Class I; Level of Evidence: C)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Mechanical Prosthesis
 
 
 
 
 
Bioprosthesis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient with risk factors
 
Patient without risk factors
 
AVR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Give warfarin to achieve INR of 3.0
❑ Give aspirin 75-100 mg/d
❑ Both long term
 
❑ Give warfarin to achieve INR of 2.5
❑ Give aspirin 75-100 mg/d
❑ Both long term
 
❑ Give warfarin to achieve INR of 2.5 for 3 months
❑ Then give aspirin 75-100 mg/d long term
 
❑ Give clopidogrel 75 mg/d
❑ Give aspirin 75-100 mg/d
❑ Both for 6 months
 


❑ Either a bioprosthetic or mechanical valve is reasonable in patients between 60 and 70 years of age. (Class IIa; Level of Evidence: B).

Do's

❑ Give ACE inhibitors to control hypertension in patients with asymptomatic aortic stenosis. [7]
❑ Exercise testing in asymptomatic patients with AS may be considered to elicit exercise-induced symptoms and abnormal blood pressure responses (Class IIb; Level of Evidence: B).
❑ Dobutamine stress echocardiography is reasonable to evaluate patients with low-flow/low-gradient AS and LV dysfunction (Stage D3) (Class IIa; Level of Evidence: B)
❑ Aortic balloon valvotomy might be reasonable as a bridge to surgery in hemodynamically unstable adult patients with AS who are at high risk for AVR or cannot be performed because of serious comorbid conditions.(Class IIb; Level of Evidence: C).

Don'ts

❑ Do not perform a stress test in a symptomatic patient with stage D aortic stenosis (Class III; Level of Evidence: B).
❑ Do not give statins to prevent hemodynamic progression in patients with mild to moderate calcific aortic valve disease (Class III; Level of Evidence: A).
TAVR is not recommended in patients in whom existing comorbidities would preclude the expected benefit from correction of AS (Class III; Level of Evidence: B)
❑ Do not give vasodilators to patients with severe AS as they may cause severe hypotension.
Endocarditis prophylaxis is not indicated in patients with AR. [8]

References

  1. 1.0 1.1 1.2 "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary". Retrieved 4 March 2014.
  2. Bonow, R. O.; Carabello, B. A.; Chatterjee, K.; de Leon, A. C.; Faxon, D. P.; Freed, M. D.; Gaasch, W. H.; Lytle, B. W.; Nishimura, R. A.; O'Gara, P. T.; O'Rourke, R. A.; Otto, C. M.; Shah, P. M.; Shanewise, J. S. (2008). "2008 Focused Update Incorporated Into the 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): Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–e661. doi:10.1161/CIRCULATIONAHA.108.190748. ISSN 0009-7322.
  3. 3.0 3.1 Ben-Dor, I.; Pichard, A. D.; Gonzalez, M. A.; Weissman, G.; Li, Y.; Goldstein, S. A.; Okubagzi, P.; Syed, A. I.; Maluenda, G.; Collins, S. D.; Delhaye, C.; Wakabayashi, K.; Gaglia, M. A.; Torguson, R.; Xue, Z.; Satler, L. F.; Suddath, W. O.; Kent, K. M.; Lindsay, J.; Waksman, R. (2010). "Correlates and Causes of Death in Patients With Severe Symptomatic Aortic Stenosis Who Are Not Eligible to Participate in a Clinical Trial of Transcatheter Aortic Valve Implantation". Circulation. 122 (11_suppl_1): S37–S42. doi:10.1161/CIRCULATIONAHA.109.926873. ISSN 0009-7322.
  4. 4.0 4.1 "Online STS Risk Calculator". Retrieved 7 March 2014.
  5. 5.0 5.1 "http://www.euroscore.org/calc.html". Retrieved 7 March 2014. External link in |title= (help)
  6. Smith, Craig R.; Leon, Martin B.; Mack, Michael J.; Miller, D. Craig; Moses, Jeffrey W.; Svensson, Lars G.; Tuzcu, E. Murat; Webb, John G.; Fontana, Gregory P.; Makkar, Raj R.; Williams, Mathew; Dewey, Todd; Kapadia, Samir; Babaliaros, Vasilis; Thourani, Vinod H.; Corso, Paul; Pichard, Augusto D.; Bavaria, Joseph E.; Herrmann, Howard C.; Akin, Jodi J.; Anderson, William N.; Wang, Duolao; Pocock, Stuart J. (2011). "Transcatheter versus Surgical Aortic-Valve Replacement in High-Risk Patients". New England Journal of Medicine. 364 (23): 2187–2198. doi:10.1056/NEJMoa1103510. ISSN 0028-4793.
  7. Chambers, J. (2005). "The left ventricle in aortic stenosis: evidence for the use of ACE inhibitors". Heart. 92 (3): 420–423. doi:10.1136/hrt.2005.074112. ISSN 1355-6037.
  8. Bonow, RO.; Carabello, BA.; Chatterjee, K.; de Leon, AC.; Faxon, DP.; Freed, MD.; Gaasch, WH.; Lytle, BW.; Nishimura, RA. (2008). "2008 Focused update incorporated into the 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): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". Circulation. 118 (15): e523–661. doi:10.1161/CIRCULATIONAHA.108.190748. PMID 18820172. Unknown parameter |month= ignored (help)


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