Aortic stenosis general approach
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Resident Survival Guide |
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Aortic Stenosis Microchapters |
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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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Aortic stenosis general approach On the Web |
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Risk calculators and risk factors for Aortic stenosis general approach |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Mohammed A. Sbeih, M.D. [2]; Rim Halaby; Usama Talib, BSc, MD [3]
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.[1] 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.[2]
General Approach
The general approach to treating Aortic Valve Stenosis has the following important aspects.[3]
- 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.[4]
- Patients undergoing aortic valve replacement and having co-existing multi-vessel coronary artery disease should have concomitantly CABG.[5]
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.[5][6]
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.[1]
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%[6] | ||||||||||||||||||||||
| 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
Following are some of the available therapeutic options for Aortic Stenosis.[3][7]
- Aortic stenosis surgery via aortic valve replacement
- Transcatheter aortic valve implantation
- Percutaneous aortic balloon valvotomy (PABV) or aortic valvuloplasty
- Medical management
ESC/EACTS Guidelines
Indications for Intervention in Aortic Stenosis and Recommendations for the Choice of Intervention Mode[8]
| Symptomatic Aortic Stenosis | Class of Recommendation | Level of Evidence |
|---|---|---|
| Intervention is indicated in symptomatic patients with severe, high-gradient aortic stenosis (mean gradient ≥ 40 mmHg or peak velocity ≥ 4.0 m/s) | I | B |
| Intervention is indicated in symptomatic patients with severe low-flow, low-gradient (< 40 mmHg) aortic stenosis with reduced ejection fraction and evidence of flow (contractile) reserve excluding pseudosevere aortic stenosis | I | C |
| Intervention should be considered in symptomatic patients with low-flow, low-gradient (< 40 mmHg) aortic stenosis with normal ejection fraction after careful confirmation of severe aortic stenosis | IIa | C |
| Intervention should be considered in symptomatic patients with low-flow, low-gradient aortic stenosis and reduced ejection fraction without flow (contractile) reserve, particularly when CT calcium scoring confirms severe aortic stenosis | IIa | C |
| Intervention should not be performed in patients with severe comorbidities when the intervention is unlikely to improve quality of life or survival | III | C |
| Choice of Intervention in Symptomatic Aortic Stenosis | ||
| Aortic valve interventions should only be performed in centres with both departments of cardiology and cardiac surgery on site and with structured collaboration between the two, including a Heart Team (heart valve centres) | I | C |
| The choice for intervention must be based on careful individual evaluation of technical suitability and weighing of risks and benefits of each modality. In addition, the local expertise and outcomes data for the given intervention must be taken into account | I | C |
| SAVR is recommended in patients at low surgical risk (STS or EuroSCORE II < 4% or logistic EuroSCORE I < 10%d and no other risk factors not included in these scores, such as frailty, porcelain aorta, sequelae of chest radiation) | I | B |
| TAVI is recommended in patients who are not suitable for SAVR as assessed by the Heart Team | I | B |
| In patients who are at increased surgical risk (STS or EuroSCORE II ≥ 4% or logistic EuroSCORE I ≥ 10%d or other risk factors not included in these scores such as frailty, porcelain aorta, sequelae of chest radiation), the decision between SAVR and TAVR should be made by the Heart Team according to the individual patient characteristics, with TAVR being favored in elderly patients suitable for transfemoral access | I | B |
| Balloon aortic valvotomy may be considered as a bridge to SAVR or TAVR in hemodynamically unstable patients or in patients with symptomatic severe aortic stenosis who require urgent major non-cardiac surgery | IIb | C |
| Balloon aortic valvotomy may be considered as a diagnostic means in patients with severe aortic stenosis or other potential causes for symptoms (i.e. lung disease) and in patients with severe myocardial dysfunction, pre-renal insufficiency, or other organ dysfunction that may be reversible with balloon aortic valvotomy when performed in centers that can escalate to TAVR | IIb | C |
| Asymptomatic Patients With Severe Aortic Stenosis (Refers Only to Patients Eligible for Surgical Valve Replacement) | ||
| SAVR is indicated in asymptomatic patients with severe aortic stenosis and systolic LV dysfunction (LVEF < 50%) not due to another cause | I | C |
| SAVR is indicated in asymptomatic patients with severe aortic stenosis and an abnormal exercise test showing symptoms on exercise clearly related to aortic stenosis | I | C |
| SAVR should be considered in asymptomatic patients with severe aortic stenosis and an abnormal exercise test showing a decrease in blood pressure below baseline | IIa | C |
SAVR should be considered in asymptomatic patients with normal ejection fraction and none of the above-mentioned exercise test abnormalities if the surgical risk is low and one of the following findings is present:
|
IIa | C |
| Concomitant Aortic Valve Surgery at the Time of Other Cardiac/Ascending Aorta Surgery | ||
| SAVR is indicated in patients with severe aortic stenosis undergoing CABG or surgery of the ascending aorta or of another valve | I | C |
| SAVR should be considered in patients with moderate aortic stenosis undergoing CABG or surgery of the ascending aorta or of another valve after Heart Team decision | IIa | C |
| BNP = B-type natriuretic peptide; CABG = coronary artery bypass grafting; CT = computed tomography; EuroSCORE = European System for Cardiac Operative Risk Evaluation; LV = left ventricular; LVEF = left ventricular ejection fraction; SAVR = surgical aortic valve replacement; STS = Society of Thoracic Surgeons; TAVR = transcatheter aortic valve replacement; Vmax = peak transvalvular velocity | ||
References
- ↑ 1.0 1.1 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.
- ↑ 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) - ↑ 3.0 3.1 Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (23): e1–121. doi:10.1016/j.jacc.2008.10.001. PMID 19038677.
- ↑ Jean-Luc Monin, Jean-Paul Quere, Mehran Monchi, Helene Petit, Serge Baleynaud, Christophe Chauvel, Camelia Pop, Patrick Ohlmann, Claude Lelguen, Patrick Dehant, Christophe Tribouilloy & Pascal Gueret (2003). "Low-gradient aortic stenosis: operative risk stratification and predictors for long-term outcome: a multicenter study using dobutamine stress hemodynamics". Circulation. 108 (3): 319–324. doi:10.1161/01.CIR.0000079171.43055.46. PMID 12835219. Unknown parameter
|month=ignored (help) - ↑ 5.0 5.1 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.
- ↑ 6.0 6.1 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.
- ↑ Vahl TP, Kodali SK, Leon MB (2016). "Transcatheter Aortic Valve Replacement 2016: A Modern-Day "Through the Looking-Glass" Adventure". J Am Coll Cardiol. 67 (12): 1472–87. doi:10.1016/j.jacc.2015.12.059. PMID 27012409.
- ↑ Baumgartner, Helmut; Falk, Volkmar; Bax, Jeroen J; De Bonis, Michele; Hamm, Christian; Holm, Per Johan; Iung, Bernard; Lancellotti, Patrizio; Lansac, Emmanuel; Rodriguez Muñoz, Daniel; Rosenhek, Raphael; Sjögren, Johan; Tornos Mas, Pilar; Vahanian, Alec; Walther, Thomas; Wendler, Olaf; Windecker, Stephan; Zamorano, Jose Luis; Roffi, Marco; Alfieri, Ottavio; Agewall, Stefan; Ahlsson, Anders; Barbato, Emanuele; Bueno, Héctor; Collet, Jean-Philippe; Coman, Ioan Mircea; Czerny, Martin; Delgado, Victoria; Fitzsimons, Donna; Folliguet, Thierry; Gaemperli, Oliver; Habib, Gilbert; Harringer, Wolfgang; Haude, Michael; Hindricks, Gerhard; Katus, Hugo A; Knuuti, Juhani; Kolh, Philippe; Leclercq, Christophe; McDonagh, Theresa A; Piepoli, Massimo Francesco; Pierard, Luc A; Ponikowski, Piotr; Rosano, Giuseppe M C; Ruschitzka, Frank; Shlyakhto, Evgeny; Simpson, Iain A; Sousa-Uva, Miguel; Stepinska, Janina; Tarantini, Giuseppe; Tchétché, Didier; Aboyans, Victor; Windecker, Stephan; Aboyans, Victor; Agewall, Stefan; Barbato, Emanuele; Bueno, Héctor; Coca, Antonio; Collet, Jean-Philippe; Coman, Ioan Mircea; Dean, Veronica; Delgado, Victoria; Fitzsimons, Donna; Gaemperli, Oliver; Hindricks, Gerhard; Iung, Bernard; Jüni, Peter; Katus, Hugo A; Knuuti, Juhani; Lancellotti, Patrizio; Leclercq, Christophe; McDonagh, Theresa; Piepoli, Massimo Francesco; Ponikowski, Piotr; Richter, Dimitrios J; Roffi, Marco; Shlyakhto, Evgeny; Simpson, Iain A; Zamorano, Jose Luis; Kzhdryan, Hovhannes K; Mascherbauer, Julia; Samadov, Fuad; Shumavets, Vadim; Camp, Guy Van; Lončar, Daniela; Lovric, Daniel; Georgiou, Georgios M; Linhartova, Katerina; Ihlemann, Nikolaj; Abdelhamid, Magdy; Pern, Teele; Turpeinen, Anu; Srbinovska-Kostovska, Elizabeta; Cohen, Ariel; Bakhutashvili, Zviad; Ince, Hüseyin; Vavuranakis, Manolis; Temesvári, András; Gudnason, Thorarinn; Mylotte, Darren; Kuperstein, Rafael; Indolfi, Ciro; Pya, Yury; Bajraktari, Gani; Kerimkulova, Alina; Rudzitis, Ainars; Mizariene, Vaida; Lebrun, Frédéric; Demarco, Daniela Cassar; Oukerraj, Latifa; Bouma, Berto J; Steigen, Terje Kristian; Komar, Monika; De Moura Branco, Luisa Maria; Popescu, Bogdan A; Uspenskiy, Vladimir; Foscoli, Marina; Jovovic, Ljiljana; Simkova, Iveta; Bunc, Matjaz; de Prada, José Antonio Vázquez; Stagmo, Martin; Kaufmann, Beat Andreas; Mahdhaoui, Abdallah; Bozkurt, Engin; Nesukay, Elena; Brecker, Stephen J D (2017). "2017 ESC/EACTS Guidelines for the management of valvular heart disease". European Heart Journal. 38 (36): 2739–2791. doi:10.1093/eurheartj/ehx391. ISSN 0195-668X.