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Aortic stenosis

AS is a chronic fibrocalcific disease that results in narrowing of the aortic valve.
AS is caused by the interplay of structural (e.g., bicuspid aortic valve), hereditary (e.g., genetic polymorphisms of lipoprotein A gene), and acquired (e.g., progressive age-related calcification, rheumatic valve disease) factors. Turbulent flow through a stenotic aortic valve causes endothelial damage, with subsequent subendothelial inflammation and accumulation of oxidized lipoproteins, and leads to deposition of calcium on the valve with progression of stenosis.
The prevalence of AS in the US is estimated at 400 persons per 100,000 population. The incidence of AS-related admissions in the US is estimated at 9.5-26 cases per 100,000 patient-years.
Disease course
AS results in obstruction to the ejection of blood the left ventricle, with resultant signs and symptoms of left-sided HF.
Prognosis and risk of recurrence
The overall survival of elderly patients with severe AS is 3 years from the onset of symptoms. In patients with severe, symptomatic AS who are at prohibitive risk for aortic valve replacement, the 1-year and 5-year mortality rates are 50% and > 90%, respectively.
Key sources
The following summarized guidelines for the evaluation and management of aortic stenosis are prepared by our editorial team based on guidelines from the European Society of Hypertension (ESH 2023), the American Heart Association (AHA/ACC 2021), and the European Society of Cardiology (ESC/EACTS 2021).


1.Diagnostic investigations

Transthoracic echocardiogram
Obtain TTE for accurate diagnosis of the cause of AS, assessment of hemodynamic severity, measurement of LV size and systolic function, and determination of prognosis and timing of valve intervention in patients with signs or symptoms of AS.
Consider calculating the ratio of the outflow tract to aortic velocity to further define severity in patients with suspected low-flow, low-gradient severe AS with normal or reduced LVEF (stages D2-D3).
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2.Diagnostic procedures

Coronary angiography
Obtain coronary angiography before valve surgery in patients with severe VHD and any of the following:
history of CVD
suspected myocardial ischemia
LV systolic dysfunction
age > 40 for males
≥ 1 cardiovascular risk factors
Consider obtaining coronary CTA as an alternative to coronary angiography before valve surgery in patients with severe VHD and low probability of coronary artery disease.

3.Medical management

Antihypertensive therapy
As per ESH 2023 guidelines:
Use the same BP thresholds, targets, and drug treatment strategies in patients with AS as for the general population with hypertension.
Lower BP more cautiously to avoid an excessive fall in BP and recurrent syncope in patients with high-grade AS, particularly with a history of syncope.

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4.Therapeutic procedures

Percutaneous aortic balloon dilation: as per AHA 2021 guidelines, consider performing percutaneous aortic balloon dilation as a bridge to SAVR or TAVI in critically ill patients with severe AS.

5.Surgical interventions

Aortic valve replacement, risk assessment: calculate individual risks for specific surgical and/or transcatheter procedures, using on-line tools when available, in patients with valvular heard disease when an intervention is contemplated, and discuss those risks before the procedure as a part of a shared decision-making process.

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  • Aortic valve replacement (indications)

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6.Specific circumstances

Pregnant patients: consider performing valve intervention before pregnancy in asymptomatic female patients with severe AS (aortic velocity ≥ 4.0 m/s or mean pressure gradient ≥ 40 mmHg, stage C) considering pregnancy.
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7.Preventative measures

Prevention of infective endocarditis
Consider administering antibiotic prophylaxis before dental procedures (involving manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa) in patients with VHD having any of the following:
prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts
prosthetic material used for cardiac valve repair, such as annuloplasty rings, chords, or clips
previous infective endocarditis
unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or prosthetic device
cardiac transplant with valve regurgitation attributable to a structurally abnormal valve
Do not administer antibiotic prophylaxis for non-dental procedures (such as TEE, EGD, colonoscopy, or cystoscopy) in the absence of active infection in patients with VHD at high risk of infective endocarditis.

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8.Follow-up and surveillance

Indications for referral
Evaluate patients with severe VHD by a multidisciplinary heart valve team when intervention is considered.
Consider consulting with or referring to a primary or comprehensive heart valve center when discussing treatment options for:
asymptomatic patients with severe VHD
patients likely to benefit from valve repair versus valve replacement
patients with multiple comorbidities considered for valve intervention

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