My Chest Hurts! Could it be Aortic Stenosis?

From Dr. Brickner’s lecture on valvular heart disease, here is a review of aortic stenosis:

Etiology

  • Degenerative  (dystrophic, calcific)
    • Atherosclerotic deposits and calcium in the cusps, along commissures, present age 70-80
  • Congenital (usually bicuspid)
    • Calcification along commissures, present age 40-50calcified-aortic-valve-bicuspid
  • Rheumatic
    • Fibrosis and calcification of leaflets and commissures, often associated with mitral valve disease

Exam

  • Pulsus lentus, tardus, et parvus
  • Sustained PMI
  • A2 decreased
  • Crescendo-decrescendo systolic murmur – time to peak correlates with severity

Symptoms

  • Chest pain
  • Syncope
  • Heart failure

Clinical questions for echo in AS

  • Confirm the presence and severity of AS
  • Assess LV size, degree of LVH, systolic and diastolic function
  • Assess aortic root dimensions
  • Serial follow up
  • Dobutamine stress for low gradient AS with depressed LV systolic function

Severity of aortic stenosis

Recommendations for classification of AS severity
Aortic sclerosis Mild Moderate Severe
Aortic jet velocity (m/s) ≤2.5 m/s 2.6-2.9 3.0-4.0 >4.0
Mean gradient (mmHg) <20 (<30a) 20-40b (30-50a) >40b (>50a)
AVA (cm2) >1.5 1.0-1.5 <1
Indexed AVA (cm2/m2) >0.85 0.60-0.85 <0.6
Velocity ratio >0.50 0.25-0.50 <0.25
  • aESC Guidelines.
  • bAHA/ACC Guidelines.

Treatment

  • Clinical follow-up of asymptomatic pts: yearly if severe AS, every 1-2 years for moderate AS, every 3-5 years for mild AS
  • Surgical Therapy: valve replacement for symptoms
  • Indications for TAVR
    • Class I: patients with an indication for AVR who have prohibitive surgical mortality and an expected survival post-TAVR > 12 months (level of evidence – B)
    • Class IIb: TAVR is a reasonable alternative to AVR for pts with high surgical risk (STS score > 10)