Aortic stenosis: obstruction of blood flow across the aortic valve.

The patient with AS is generally asymptomatic for a prolonged period. There is wide variability
in the degree of outflow obstruction that causes symptoms, depending in part upon patient size
and level of physical activity.
 Congenital, calcific (dystrophic calcification) and rheumatic.

Stages:
 Stage A: at risk (asymptomatic)
o Pt with bicuspid aortic valve or sclerosis
 Stage B: progressive (asymptomatic)
 Stage C1: asymptomatic severe AS with normal LVEF
 Stage C2: asymptomatic severe AS with low LVEF
 Stage D1: Symptomatic severe high-gradient AS
 Stage D2: Symptomatic severe low-gradient AS with low LVEF
 Stage D3: Symptomatic severe low-gradient AS with normal LVEF

Presentation:
 Crescendo-decrescendo systolic ejection murmur with soft S2 (ejection click may be
present)
 Loudest at heart base
 Radiates to carotids
 Pulsus parvus et tardus: pulses are weak with a delayed peak
 Can lead to SAD: syncope, angina and dyspnea on exertion
 Most common due to age related calcification in older patients (>60y/o) or in younger
with early-onset calcification of bicuspid aortic valve
 Paradoxical splitting (delay in aortic valve closure)
Diagnosis:
 Echocardiogram
 Cardiac catheterization for hemodynamic measurements to assess the severity of AS is
rarely needed except during interventional procedures to treat AS.
 Low-dose dobutamine stress test may also be helpful in symptomatic patients with
findings consistent with paradoxical LFLG AS, although data are limited. In addition, the
test provides information on LV contractile reserve, which is helpful for prognostic
purposes in contemplating possible surgical aortic valve replacement or transcatheter
aortic valve implantation (TAVI)
 Cardiovascular magnetic resonance provides accurate measurements of the size and
shape of the aortic sinuses and ascending aorta, as well as 4D flow patterns, particularly
in patients with AS due to bicuspid aortic valve disease. CMR also may show myocardial
fibrosis and increased extracellular myocardial volumes, although the role of these
findings in clinical decision-making has not yet been defined
 Severe aortic stenosis:
o Mean gradient: >40mmHg
o Peak aortic velocity of >4m/s
o Aortic valve area (AVA) <1cm2

Complications:
 HF, Pulm HTN, sudden cardiac death (annual incidence of 1%), arrythmias, endocarditis,
bleeding and embolic events.

Management:
 CHF with severe aortic stenosis: echo with dobutamine:
 Mechanical (long duration: younger pts) vs prosthetic (older pts)
 Percutaneous balloon aortic valvotomy (BAV) is not a substitute for valve replacement
in adults with symptomatic calcific aortic stenosis (AS) as it generally offers only
transient symptomatic and hemodynamic relief, does not improve long-term survival.
 Aortic valve replacement (surgical aortic valve replacement [SAVR] or transcatheter
aortic valve implantation [TAVI]) is the mainstay of treatment of symptomatic calcific AS,
offering substantial improvements in symptoms and life expectancy.
 For patients with severely symptomatic calcific AS (eg, with refractory pulmonary edema
or cardiogenic shock), percutaneous BAV may be used as a bridge to SAVR or TAVI.

Pharmacologic therapy
Agents used in the treatment of patients with aortic stenosis include the following:
 Digitalis, diuretics, and angiotensin-converting enzyme (ACE) inhibitors: Can be
cautiously used in patients with pulmonary congestion
 Vasodilators: May be used to treat for heart failure and for hypertension but
should also be employed with extreme caution
  Digoxin, diuretics, ACE inhibitors, or angiotensin receptor blockers:
Recommended by the European Society of Cardiology (ESC)/European Association
for Cardio-Thoracic Surgery (EACTS) guidelines for patients with heart failure
symptoms who are not suitable candidates for surgery or transcatheter aortic
valve implantation
Aortic valve replacement
According to American College of Cardiology (ACC)/American Heart Association (AHA)
guidelines, candidates for aortic valve replacement include the following patients [6] :
 Symptomatic patients with severe aortic stenosis
 Patients with asymptomatic, severe aortic stenosis undergoing CABG
 Patients with asymptomatic, severe aortic stenosis undergoing surgery on the
aorta or other heart valves
 Patients with asymptomatic, severe aortic stenosis and left ventricular systolic
dysfunction (ejection fraction < 0.50)