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]


Synonyms and keywords: AS; critical AS; tight AS; aortic valve stenosis; calcific aortic stenosis; senile calcific aortic stenosis; degenerative calcific aortic stenosis

Aortic Stenosis Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Choice of Intervention
Type of Valve and Discharge Anticoagulation Therapy
Do's
Don'ts

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 to peripheral tissues, however, symptoms normally appear when the stenosis is ≤ 1.0 cm². The most common etiology of aortic stenosis is calcific aortic valve disease. The management will depend if the patient is symptomatic or asymptomatic. Surgical intervention is the treatment of choice for patients with symptomatic aortic stenosis.

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

Diagnosis

Shown below is an algorithm summarizing the diagnostic approach to aortic stenosis based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease [1]

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; TTE: Transthoracic echocardiography

 
 
 
 
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:

Vitals
Heart rate

❑ Rhythm and rate are normal in most cases
❑ Arrhythmic (suggestive of AF in late stage disease)

Blood pressure

Narrow pulse pressure

Respiratory rate:

❑ Normal in most cases
Tachypnea (suggestive of HF)

Cardiovascular
Cardiac palpation

Apical impulse (suggestive of LVH)
Systolic thrill

❑ Pulses

Pulsus parvus et tardus
Pulsus bisferiens (suggestive of mixed aortic stenosis and regurgitation)

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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❑ Heart sounds:

❑ Normal S1
Paradoxical splitting of S2 (not seen in early disease)
S3 may be present (suggestive of LVH)

Respiratory
Rales (suggestive of congestive heart failure)


Extremities
Peripheral edema (suggestive of congestive heart failure)

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order imaging and adjuvant studies:

ECG (shows non-specific findings):

LVH
❑ Left atrium enlargement
LBBB
AF (in late disease)

CXR:

Cardiomegaly
Valve calcification
❑ Dilatation of ascending aorta
Pulmonary congestion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order an TTE (Class I; Level of Evidence: B)
❑ Assess the following:
❑ Valve morphology
❑ Pressure gradient
Aortic valve area
Ejection fraction
❑ LV wall thickness and motility
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
 
Control hypertension (Class I; Level of Evidence: B)
Perform a periodic echocardiogram (Class I; Level of Evidence:B)
❑ Every 3 -5 years for mild stenosis
❑ Every 1 - 2 years for moderate stenosis
 
 
 
Asymptomatic
(Stage C)
 
 
 
 
Symptomatic
(Stage D)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If patient is unstable:
❑ Administer vasodilation therapy with invasive hemodynamic monitoring (Class IIb; Level of Evidence: C)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 based on the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease [1]

 
 
 
 
 
 
Patient scheduled for AVR
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High risk
 
 
 
 
 
Low to moderate risk
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ 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] [2]
 
 
 
 
 
❑ Schedule for surgical AVR (Class I; Level of Evidence: A)
 
 
 
 

Evaluation of Surgical and Interventional Cardiac Risk

Shown below is a table to assess the surgical and interventional risk which combines the STS risk estimate, frailty, major organ system dysfunction and procedure-specific impediments.[1]

Low risk Intermediate risk High risk Prohibitive risk
STS PROM <4%
AND
4% to 8%
OR
>8%
OR
Predicted risk of death or major morbidity (all-cause) >50% at 1 year
OR
Frailty* None
AND
1 index
OR
≥2 indices (moderate to severe)
OR
Predicted risk of death or major morbidity (all-cause) >50% at 1 year
OR
Major organ system compromise not to be improved postoperatively None
AND
1 organ system
OR
No more than 2 organ systems
OR
≥3 organ systems
OR
Procedure-specific impediment** None
Possible procedure-specific impediment Possible procedure-specific impediment Severe procedure-specific impediment

STS PROM: Society of Thoracic Surgeons Predicted Risk of Mortality Score.[3]
*Seven frailty indices: Katz Activites of Daily Living (self-sufficient in feeding, bathing, dressing, transferring, toileting and urinary continence) and self-sufficient in deambulation (no walking aid or assist required or 5-meter walk in <6 s).
**Procedure-specific impediment examples: tracheostomy present, heavily calcified ascending aorta, chest malformation, arterial coronary graft adherent to posterior chest wall or radiation damage.

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. [4]
❑ 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 AS. [5]

References

  1. 1.0 1.1 1.2 1.3 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.
  2. 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.
  3. "Online STS Risk Calculator". Retrieved 7 March 2014.
  4. 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.
  5. 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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