Aortic valve stenosis

Rheumatic fever is now rare in the Greece, but still common in developing countries and can scar the aortic valve.

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Treatment depends on the severity of the condition. You may need surgery to repair or replace the valve. Left untreated, aortic valve stenosis can lead to serious heart problems

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Symptoms

 

Aortic valve stenosis ranges from mild to severe. Aortic valve stenosis signs and symptoms generally develop when narrowing of the valve is severe. Some people with aortic valve stenosis may not experience symptoms for many years. Signs and symptoms of aortic valve stenosis may include:

 

• Abnormal heart sound (heart murmur) heard through a stethoscope

• Chest pain (angina) or tightness with activity

• Feeling faint or dizzy or fainting with activity

• Shortness of breath, especially when you are active

• Fatigue, especially during times of increased activity

• Heart palpitations — sensations of a rapid, fluttering heartbeat

 

The heart-weakening effects of aortic valve stenosis may lead to heart failure. Heart failure signs and symptoms include fatigue, shortness of breath, and swollen ankles and feet.

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Causes

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The heart has four valves that keep blood flowing in the correct direction. These valves include the mitral valve, tricuspid valve, pulmonary valve and aortic valve. Each valve has flaps (cusps or leaflets) that open and close once during each heartbeat. Sometimes, the valves don't open or close properly, disrupting the blood flow through the heart and potentially impairing the ability to pump blood to the body.

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In aortic valve stenosis, the aortic valve between the lower left heart chamber (left ventricle) and the main artery (aorta) that delivers blood from the heart to the body is narrowed.

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When the aortic valve is narrowed, the left ventricle has to work harder to pump a sufficient amount of blood into the aorta and onward to the rest of the body. This can cause the left ventricle to thicken and enlarge. Eventually the extra work of the heart can weaken the left ventricle and the heart overall, and it can ultimately lead to heart failure and other problems.

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Aortic valve stenosis can occur due to many causes, including:

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Congenital heart defect. The aortic valve consists of three tightly fitting, triangular-shaped flaps of tissue called cusps. Some children are born with an aortic valve that has only two (bicuspid) cusps instead of three. People may also be born with one (unicuspid) or four (quadricuspid) cusps, but these are rare.

This defect may not cause any problems until adulthood, at which time the valve may begin to narrow or leak and may need to be repaired or replaced.

Having a congenitally abnormal aortic valve requires regular evaluation by a doctor to watch for signs of valve problems.

 

Calcium buildup on the valve. With age, heart valves may accumulate deposits of calcium (aortic valve calcification). Calcium is a mineral found in the blood. As blood repeatedly flows over the aortic valve, deposits of calcium can build up on the valve's cusps.

These deposits may never cause any problems. However, in some people — particularly those with a congenitally abnormal aortic valve, such as a bicuspid aortic valve — calcium deposits result in stiffening of the cusps of the valve. This stiffening narrows the aortic valve and can occur at a younger age.

However, aortic valve stenosis that is related to increasing age and the buildup of calcium deposits on the aortic valve is most common in older people. It usually doesn't cause symptoms until ages 70 or 80.

 

Rheumatic fever. A complication of strep throat infection called rheumatic fever may result in scar tissue forming on the aortic valve. Scar tissue alone can narrow the aortic valve and lead to aortic valve stenosis. Scar tissue can also create a rough surface on which calcium deposits can collect, contributing to aortic valve stenosis later in life.

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Rheumatic fever may damage more than one heart valve, and in more than one way. A damaged heart valve may not open fully or close fully — or both.

 

Risk factors

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Risk factors of aortic valve stenosis include:

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• Older age

• Certain heart conditions present at birth (congenital heart disease) such as a bicuspid aortic valve

• History of infections that can affect the heart

• Having cardiovascular risk factors, such as diabetes, high cholesterol and high blood pressure

• Chronic kidney disease

• History of radiation therapy to the chest

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Complications

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Aortic valve stenosis can cause complications, including:

 

• Heart failure

• Stroke

• Blood clots

• Bleeding

• Heart rhythm abnormalities (arrhythmias)

• Infections that affect the heart, such as endocarditis

• Death

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Prevention

 

Some possible ways to prevent aortic valve stenosis include:

 

Taking steps to prevent rheumatic fever. You can do this by making sure you see your doctor when you have a sore throat. Untreated strep throat can develop into rheumatic fever. Fortunately, strep throat can usually be easily treated with antibiotics. Rheumatic fever is more common in children and young adults.

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Addressing risk factors for coronary artery disease. These include high blood pressure, obesity and high cholesterol levels. These factors may be linked to aortic valve stenosis, so it's a good idea to keep your weight, blood pressure and cholesterol levels under control if you have aortic valve stenosis.

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Taking care of your teeth and gums. There may be a link between infected gums (gingivitis) and infected heart tissue (endocarditis). Inflammation of heart tissue caused by infection can narrow arteries and aggravate aortic valve stenosis.

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Once you know that you have aortic valve stenosis, your doctor may recommend that you limit strenuous activity to avoid overworking your heart.

 

Diagnosis

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For the diagnosis of the aortic valve stenosis, your doctor will take into consideration the symptoms, the medical history, and the physical examination. Your doctor may listen to your heart to fund out if there is a heart murmur that indicates aortic valve stenosis.

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Several tests should be ordered to diagnose and determine the cause and severity of the condition. Tests may include:

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Echocardiogram. This test provides video images of the heart in motion.  It is a useful test that evaluates the heart chambers, the aortic valve and the blood flow in to the heart.

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This test can help doctors closely look at the condition of the aortic valve, the cause and severity of the disease. It is also helpful for doctors at determining if there is any additional valve disorder. Doctors may need a different type of echocardiogram called a transesophageal echocardiogram to get a closer look at the aortic valve.

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Electrocardiogram (ECG). In this test, wires (electrodes) attached on your skin record the electrical activity of the heart. An ECG can detect enlarged chambers of the heart and any arrhythmia.

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Chest X-ray. A chest X-ray can detect if the heart is enlarged, which happens in aortic valve stenosis. It can also find any potential aortic calcification or aneurysm. Furthermore, it can assess the condition of the lungs.

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Exercise tests. Exercise tests detects if you have symptoms of aortic valve disease during physical activity, and is also useful to determine the severity.

 

Cardiac computerized tomography (CT) scan. A cardiac CT scan may show detailed images of the heart and heart valves. Cardiac MRI. A cardiac MRI uses magnetic fields and radio waves to create detailed images of your heart. This test may be used to determine the severity of the disorder and to look for potential aortic aneurysm.

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Cardiac catheterization. This test isn't often used for the diagnosis aortic valve disease, but it may be used in order to have more detailed information of the heart.

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During this procedure, your doctor inserts a catheter into a artery of the arm or groin and guides it to the heart.

Doctors may inject a dye through the catheter, which makes the arteries become visible on an X-ray (coronary angiogram). This provides a detailed information of the heart arteries and how heart functions.

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Treatment

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Treatment for aortic valve stenosis depends on its severity, whether there are symptoms and if the situation is getting worse.

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If your symptoms are mild or absent, monitoring of the condition with regular follow-up is needed. You will be recommended to have a healthy lifestyle changes and receive medications to improve symptoms or reduce the risk for complications.

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At some point, there will be necessary to repair or replace surgically the diseased aortic valve. In some cases, aortic valve surgery may be recommend even if there are no symptoms, or if you're going to have another heart surgery, so doctors may perform it at the same time.

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Surgery for aortic valve is usually performed with incision in the chest. Sometimes, minimal invasive approaches may be available, and your doctor will evaluate if you're a candidate for these procedures.

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If you have aortic valve stenosis, consider being evaluated and treated at a hospital with a multidisciplinary team trained and experienced in treating heart valve disease. This team can work closely with you to determine the most appropriate treatment for your condition.

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Surgery options include:

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Aortic valve repair. A few cases are candidate for stenotic aortic valve repair. Generally aortic valve stenosis requires aortic valve replacement. Doctor will discuss with the patient which technique is the most appropriate for the condition.

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Balloon valvuloplasty. Doctors may conduct a procedure using a catheter to repair aortic valve stenosis. In this procedure (balloon valvuloplasty), a doctor inserts a catheter with a balloon on the tip into an artery of the arm or groin and guides it to the aortic valve an then inflates the balloon, which expands the valve. The balloon is then deflated and removed.

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The procedure can treat aortic valve stenosis in children. However, the valve tends to narrow again in adults who've had the procedure, so it's usually only performed in adults who are too ill for surgery or who are waiting for a valve replacement, as they typically need additional procedures to treat the narrowed valve over time.

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Aortic valve replacement. Aortic valve replacement is often needed to treat aortic valve stenosis. In aortic valve replacement, your surgeon removes the damaged valve and replaces it with a mechanical valve or a valve made from cow, pig or human heart tissue (biological tissue valve).

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Biological tissue valves degenerate over time and may need to be replaced. People with mechanical valves will need to take blood-thinning medications to prevent blood clots. A discussion with the doctor is necessary regarding the benefits and risks of each type of valve, which one may be appropriate for you.

 

Transcatheter aortic valve replacement (TAVI). Doctors may perform a less invasive procedure called transcatheter aortic valve replacement (TAVI) to replace a narrowed aortic valve. TAVI may be an option for people who are considered to be at intermediate or high risk of complications from surgical aortic valve replacement.

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In TAVI, doctors insert a catheter in your leg or chest and guide it to your heart. A replacement valve is then inserted through the catheter and guided to your heart. A balloon may expand the valve, or some valves can self-expand. When the valve is implanted, doctors remove the catheter from your blood vessel.

Doctors may also conduct a catheter procedure to insert a replacement valve into a failing biological tissue valve that is no longer working properly. Other catheter procedures to repair or replace aortic valves continue to be researched.

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