• Valvular AS has three principal causes: a congenital bicuspid valve

with superimposed calcification,

• calcification of a normal trileaflet valve, and rheumatic disease
Stages of AS
• Severe obstruction to LV outflow usually is characterized by the
following:
1. An aortic jet velocity of 4 m/sec or greater;
2. A mean transvalvular pressure gradient at least 40 mm Hg in the
presence of a normal flow;
3. An effective aortic orifice (calculated by the continuity equation) no
greater than 1.0 cm2 in an average-sized adult (i.e., ≤0.6 cm2/m2 of
body surface area), which is approximately 25% of the normal aortic
orifice of 3.0 to 4.0 cm2.
• Moderate AS is characterized by
1. An aortic jet velocity of 3.0 to 3.9 m/sec or mean transvalvular
pressure gradient of 20 to 39 mm Hg
2. With an aortic valve orifice area (AVA) of 1.0 to 1.5 cm2.
• Mild AS is characterized by
1. An aortic jet velocity of 2.0 to 2.9 m/sec or mean transvalvular
pressure gradient less than 20 mm Hg,
2. Usually with aortic orifice of 1.5 to 2.0 cm2
 Stages of Valvular Aortic Stenosis
Stage Definition Valve Anatomy Valve Hemodynamic Symptoms
Hemodynamics Consequences
A At risk of AS ● Bicuspid aortic ● Aortic ● None ● None
valve (or other Vmax <2 m/s
congenital valve
anomaly)
● Aortic valve
sclerosis
B Progressive ● Mild-to-moderate ● Mild AS: Aortic ● Early LV ● None
AS leaflet calcification Vmax 2.0–2.9 diastolic
of a bicuspid or m/s or mean dysfunction
trileaflet valve with P <20 mm Hg may be
some reduction in ● Moderate AS: present
systolic motion or Aortic Vmax 3.0– ● Normal LVEF
● Rheumatic valve 3.9 m/s or
changes with
mean P 20–
commissural fusion
39 mm Hg
 Stages of Valvular Aortic Stenosis
Stage Definition Valve Anatomy Valve Hemodynamic Symptoms
Hemodynamics Consequences
C - Asymptomatic severe AS
C1 Asymptomatic ● Severe leaflet ● Aortic Vmax 4 m/s ● LV diastolic ● None–
severe AS calcification or or mean P ≥40 dysfunction exercise
congenital mm Hg ● Mild LV testing is
stenosis with ● AVA typically is hypertrophy reasonable
severely ≤1 cm2 (or AVAi ● Normal LVEF to confirm
reduced leaflet 0.6 cm2/m2) symptom
opening ● Very severe AS is status
an aortic Vmax
≥5 m/s, or mean
P ≥60 mm Hg
C2 Asymptomatic ● Severe leaflet ● Aortic Vmax ≥4 m/s ● LVEF <50% ● None
severe AS with calcification or or mean P ≥40
LV dysfunction congenital mm Hg
  stenosis with ● AVA typically is
severely ≤1 cm2 (or AVAi
reduced leaflet 0.6 cm2/m2)
opening
 Stages of Valvular Aortic Stenosis
Stage Definition Valve Anatomy Valve Hemodynamics Hemodynamic Symptoms
Consequences
D - Symptomatic severe AS
D1 Symptomatic ● Severe leaflet ● Aortic Vmax ≥4 m/s, or mean ● LV diastolic ● Exertional
severe high- calcification or P ≥40 mm Hg dysfunction dyspnea or
gradient AS congenital ● AVA typically is 1 cm2 (or ● LV hypertrophy decreased
stenosis with AVAi 0.6 cm2/m2), but may
● Pulmonary exercise
severely be larger with mixed hypertension may tolerance
reduced be present ● Exertional
AS/AR
leaflet opening angina
● Exertional
syncope or
presyncope
D2 Symptomatic ● Severe leaflet ● AVA 1 cm2 with resting ● LV diastolic ● HF,
severe low- calcification aortic Vmax <4 m/s or mean dysfunction ● Angina,
flow/low- with severely P <40 mm Hg ● LV hypertrophy ● Syncope or
gradient AS reduced ● Dobutamine stress echo
● LVEF <50% presyncope
with reduced leaflet motion shows AVA 1 cm2 with
LVEF
Vmax 4 m/s at any flow rate
 Stages of Valvular Aortic Stenosis
Stage Definition Valve Anatomy Valve Hemodynamic Symptoms
Hemodynamics Consequences
D - Symptomatic severe AS
D3 Symptomatic ● Severe leaflet ● AVA 1 cm2 with ● Increased LV ● HF,
severe low- calcification aortic Vmax <4 m/s, relative wall ● Angina,
gradient AS with severely or mean P <40 thickness ● Syncopeor
with normal reduced leaflet mm Hg ● Small LV chamber presyncope
LVEF or motion ● Indexed AVA 0.6 with low-stroke
paradoxical cm2/m2 and volume.
low-flow ● Stroke volume
● Restrictive diastolic
severe AS index <35 mL/m2 filling
● LVEF ≥50%
● Measured when
the patient is
normotensive
(systolic BP <140
mm Hg)
Diagnostic Testing
Echocardiography
• Accurate definition of valve anatomy, including the cause of AS and
the severity of valve calcification, and sometimes allows direct
imaging of the orifice area using three-dimensional imaging.
• Echocardiographic imaging also is invaluable for the evaluation of LV
hypertrophy and systolic function, with calculation of EF,
measurement of aortic sinus dimensions, and detection of associated
mitral valve disease.
• Longitudinal systolic strain imaging has emerged as a more sensitive
measure of LV function and predicts adverse clinical events, including
mortality
• Doppler echocardiography allows measurement of transaortic jet
velocity, which is the most useful measure for following disease
severity and predicting clinical outcome
 PEAK TRANSVALVULAR VELOCITY

 A smooth velocity
curve with a dense
outer edge and clear
maximum velocity
should be recorded
 Fine linear signals at
the peak of the curve
not be included
 VTI also calculated
 NO OF
MEASUREMENTS
 Sinus Rhythm – 3 Measurements
 Irregular Rhythm – 5 Measurements
 MEAN TRANSVALVULAR GRADIENT

 The difference in pressure between the left ventricle and aorta in

systole
 Gradients are calculated from velocity information
 Simplified Bernoulli equation
ΔP =4V²
 The maximum gradient is calculated from maximum velocity
ΔP max =4V² max
 The instantaneous gradient at any point of time is calculated similarly
from the instantaneous velocity
 And averaged to get the mean gradient (mean gradient not
derived from mean velocity)
 BERNOULLI
EQUATION
 The simplified Bernoulli equation assumes
that the proximal velocity can be ignored

 When the proximal velocity is over 1.5 m/s or

the aortic velocity is <3.0 m/s, the proximal
velocity should be included in the Bernoulli
equation
ΔP max =4 (v² max- v² proximal)
Exercise Stress Testing
• Helpful in apparently asymptomatic patients to unmask symptoms or
demonstrate limited exercise capacity or an abnormal BP response.
• Absolutely avoided in symptomatic patients
LOW DOSE DOBUTAMINE PROTOCOL
Aortic Stenosis: Diagnosis and Follow-Up
Recommendations COR LOE
TTE is indicated in patients with signs or symptoms of AS or a
bicuspid aortic valve for accurate diagnosis of the cause of
AS, hemodynamic severity, LV size and systolic function, and
for determining prognosis and timing of valve intervention I B

Low-dose dobutamine stress testing using echocardiographic

or invasive hemodynamic measurements is reasonable in
patients with stage D2 AS with all of the following:
a. Calcified aortic valve with reduced systolic opening;
b. LVEF less than 50%;
c. Calculated valve area 1.0 cm2 or less; and IIa B
d. Aortic velocity less than 4.0 m per second or mean
pressure gradient less than 40 mm Hg
Aortic Stenosis: Diagnosis and Follow-Up
Recommendations COR LOE
Exercise testing is reasonable to assess physiological
changes with exercise and to confirm the absence of
symptoms in asymptomatic patients with a calcified
aortic valve and an aortic velocity 4.0 m per second or IIa B
greater or mean pressure gradient 40 mm Hg or higher
(stage C)

Exercise testing should not be performed in

symptomatic patients with AS when the aortic velocity
is 4.0 m per second or greater or mean pressure III: B
gradient is 40 mm Hg or higher (stage D) Harm
Medical Therapy
• Medical therapy has not been shown to affect disease progression in
patients with AS. Furthermore, both observational studies and RCTs
convincingly demonstrate that AVR is superior to medical therapy in
patients with severe symptomatic AS
• Hypertension accompanies AS in a majority of patients.
• Because of traditional teaching that AS is a disease with fixed
afterload, there has often been reluctance to treat hypertension
because of concerns that vasodilation would not be offset by an
increase in stroke volume. However, several studies have
demonstrated that vasodilation is accompanied by increases in
stroke volume, even in patients with severe AS.
• No one class of medicines established as the preferred treatment of
hypertension in patients with AS, but because the renin-angiotensin
system is upregulated in the valve and ventricle of patients with AS,
angiotensin-converting-enzyme (ACE) inhibitors or angiotensin
receptor blockers (ARBs) may preferentially considered.
• The presence of concomitant CAD is related to the patient's age but
is common in patients with AS. Primary and secondary prevention
guidelines should be followed and the decision of whether to
prescribe a statin medication should not be influenced by the
presence of AS. RCTs testing the use of statins in patients with mild AS
to more advanced disease were adequately powered and showed no
improvement in mortality, time to AVR, or rate of AS progression in
the treatment versus placebo groups
• Atrial fibrillation (AF) or atrial flutter may also develop in up to one
third of older patients with AS, perhaps exacerbated by left atrial
enlargement related to diastolic dysfunction.
• The loss of the atrial contribution to LV filling and a sudden fall in
cardiac output may cause serious hypotension. If this occurs,AF
should be treated promptly, usually with cardioversion. New-onset
AF in a previously asymptomatic patient with severe AS may be a
marker of impending symptom onset
• In patients with heart failure (HF) and volume overload, AVR is indicated,
but diuretics may reduce congestion and provide some symptomatic relief
prior to valve replacement.
• Patients with decompensated HF may benefit from medical therapy as a
bridge to definitive therapy with valve replacement.
• Nitroprusside has been used during hemodynamic monitoring in the
intensive care unit to unload the left heart, reduce congestion, and
improve forward flow.
• Similarly, phosphodiesterase type 5 inhibition has been shown to provide
acute improvements in pulmonary and systemic hemodynamics resulting in
biventricular unloading.
Aortic Stenosis: Medical Therapy
Recommendations COR LOE
Hypertension in patients at risk for developing AS
(stage A) and in patients with asymptomatic AS
(stages B and C) should be treated according to
standard GDMT, started at a low dose, and gradually I B
titrated upward as needed with frequent clinical
monitoring

Vasodilator therapy may be reasonable if used with

invasive hemodynamic monitoring in the acute
management of patients with severe decompensated
AS (stage D) with New York Heart Association (NYHA) IIb C
class IV HF symptoms
Aortic Stenosis: Medical Therapy

Recommendations COR LOE

Statin therapy is not indicated for prevention of
hemodynamic progression of AS in patients with III: No A
mild-to-moderate calcific valve disease (stages B to Benefit
D)
Interventional Management
Balloon Aortic Valvuloplasty
• Short-term improvement in survival and quality of life, but these
benefits are not sustained.
• Not recommended as an alternate to valve replacement for calcific
AS.
• In selected cases, it might be reasonable as a bridge to definitive
treatment with AVR in unstable patients or as a palliative procedure
in patients who are not candidates for AVR.
Aortic Valve Replacement
• AVR is recommended for adults with symptomatic severe AS, even if
symptoms are mild.
• Also recommended for severe AS with a LVEF less than 50%.
• Patients with severe asymptomatic AS who are undergoing coronary
bypass grafting (CABG) or other forms of heart surgery.
• AVR is appropriate for apparently asymptomatic patients with severe
AS when exercise testing provokes symptoms or a fall in BP.
• In asymptomatic patients with severe AS and a low operative risk,
AVR may be considered when markers of rapid disease progression
are present (e.g., severe valve calcification) or when AS is very
severe, depending on patient preferences regarding the risk of earlier
intervention versus careful monitoring with intervention promptly at
symptom onset.
• After AVR, symptoms of pulmonary congestion (exertional dyspnea) and
myocardial ischemia (angina pectoris) are relieved in almost all patients,
and most patients will exhibit an improvement in exercise tolerance, even
if it was only mildly reduced before surgery.
• A reduced EF often improves and even normalizes after AVR, but impaired
longitudinal strain may still be evident.
• LV hypertrophy tends to regress after AVR, but the rate and extent of
reversal varies and is often incomplete.
• Myocardial fibrosis regresses more slowly than myocyte hypertrophy, and
thus diastolic dysfunction may improve but still persist for years after
successful valve replacement.
Surgical Aortic Valve Replacement
• Risk factors associated with a higher mortality rate include:
1. Functional class,
2. Impaired LV function
3. Advanced age,
4. The presence of associated CAD, and other comorbidities

• Advanced age should not be considered a contraindication to

operation.
Transcatheter Aortic Valve Replacement
• Superior to medical therapy (usually accompanied by balloon aortic
valvuloplasty).
• In patients deemed high risk for surgery, TAVR was shown to be
noninferior and perhaps superior to SAVR
• In intermediate-risk patients, TAVR has been shown to compare
favorably to SAVR.
• Currently, TAVR is approved in the United States for patients at
extreme, high, or intermediate risk for surgery
 Aortic Stenosis: Timing of Intervention

Recommendations COR LOE

AVR is recommended with severe high-gradient AS who
have symptoms by history or on exercise testing (stage I B
D1)
AVR is recommended for asymptomatic patients with
severe AS (stage C2) and LVEF <50% I B
AVR is indicated for patients with severe AS (stage C or
D) when undergoing other cardiac surgery I B
 Aortic Stenosis: Timing of Intervention (cont.)
Recommendations COR LOE
AVR is reasonable for asymptomatic patients with
very severe AS (stage C1, aortic velocity ≥5 m/s) IIa B
and low surgical risk
AVR is reasonable in asymptomatic patients (stage
C1) with severe AS and decreased exercise IIa B
tolerance or an exercise fall in BP
AVR is reasonable in symptomatic patients with
low-flow/low-gradient severe AS with reduced
LVEF (stage D2) with a low-dose dobutamine
stress study that shows an aortic velocity 4 m/s IIa B
(or mean pressure gradient 40 mm Hg) with a
valve area 1.0 cm2 at any dobutamine dose
 Aortic Stenosis: Timing of Intervention (cont.)
Recommendations COR LOE
AVR is reasonable in symptomatic patients who
have low-flow/low-gradient severe AS (stage D3)
who are normotensive and have an LVEF ≥50% if
clinical, hemodynamic, and anatomic data support IIa C
valve obstruction as the most likely cause of
symptoms
AVR is reasonable for patients with moderate AS
(stage B) (aortic velocity 3.0–3.9 m/s) who are IIa C
undergoing other cardiac surgery
AVR may be considered for asymptomatic patients
with severe AS (stage C1) and rapid disease IIb C
progression and low surgical risk
Indications for Aortic Valve Replacement in Patients With Aortic Stenosis
Aortic Stenosis: Choice of Intervention
Recommendations COR LOE
Modified: Surgical AVR is recommended for symptomatic
patients with severe AS (Stage D) and symptomatic patients
with severe AS (Stage C) who meet an indication for AVR when I B-NR
surgical risk is low or intermediate
For patients in whom TAVR or high-risk surgical AVR is being
considered, a heart valve team consisting of an integrated,
multidisciplinary group of healthcare professionals with
expertise in VHD, cardiac imaging, interventional cardiology, I C
cardiac anesthesia, and cardiac surgery should collaborate to
provide optimal patient care

Modified: Surgical AVR or TAVR is recommended for

symptomatic patients with severe AS (Stage D) and high risk
for surgical AVR, depending on patient-specific procedural I A
risks, values, and preferences
Aortic Stenosis: Choice of Intervention (cont.)
Recommendations COR LOE
Modified: TAVR is recommended for symptomatic
patients with severe AS (Stage D) and a prohibitive
risk for surgical AVR who have a predicted post-TAVR
survival greater than 12 months I A

New: TAVR is a reasonable alternative to surgical

AVR for symptomatic patients with severe AS (Stage
D) and an intermediate surgical risk, depending on
patient-specific procedural risks, values, and IIa B-R
preferences
Aortic Stenosis: Choice of Intervention (cont.)
Recommendations COR LOE
Percutaneous aortic balloon dilation may be
considered as a bridge to surgical or transcatheter
AVR in severely symptomatic patients with severe IIb C
AS
TAVR is not recommended in patients in whom the
existing comorbidities would preclude the expected III: No B
benefit from correction of AS Benefit
Choice of TAVR Versus Surgical AVR in the Patient
With Severe Symptomatic AS (Modified)

Severe AS Class I
Symptomatic
(stage D) Class IIa

Class IIb

Low surgical Intermediate surgical High surgical Prohibitive surgical

risk risk risk risk

Surgical AVR Surgical AVR TAVR Surgical AVR or TAVR TAVR

(Class I) (Class I) (Class IIa) (Class I) (Class I)