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Aortic stenosis
Definition
The aorta is the main artery carrying blood out of the heart. When blood leaves the heart, it flows through the aortic valve, into the aorta. In aortic stenosis, the aortic valve does not open fully. This decreases blood flow from the heart.
Alternative Names
Aortic valve stenosis; Left ventricular outflow tract obstruction; Rheumatic aortic stenosis; Calcium aortic stenosis
Causes
As the aortic valve becomes more narrow, the left ventricle has to increase pressure to pump blood out through the valve. To do this extra work, the muscles in the ventricle walls become thicker, which can lead to chest pain.
As the pressure continues to rise, blood may back up into the lungs. Severe forms of aortic stenosis prevent enough blood from reaching the brain and the rest of the body.
Aortic stenosis may be present from birth (congenital), but usually it develops later in life (is acquired). Children with aortic stenosis may have other congenital conditions.
In adults, aortic stenosis usually occurs due to calcium deposits that narrow the valve. This is called calcific aortic stenosis, and it generally affects older people.
The other common cause is rheumatic fever, a condition that may develop after strep throat or scarlet fever. Valve problems do not develop for 5 - 10 years or longer after rheumatic fever occurs. Rheumatic fever is increasingly rare in the United States.
Calcification of the valve happens sooner in patients who are born with abnormal aortic or bicuspid valves. In rare cases, calcification can also occur more quickly in patients who have received radiation treatment to the chest.
Aortic stenosis is not very common. It occurs more often in men than in women.
Symptoms
People with aortic stenosis may have no symptoms until late in the course of the disease. The diagnosis may have been made when the health care provider heard a heart murmur and performed tests.
Symptoms of aortic stenosis include:
- Breathlessness with activity
- Chest pain, angina-type
- Crushing, squeezing, pressure, tightness
- Pain increases with exercise, is relieved with rest
- Pain is felt under the chest bone but may move to other areas, most often the left side of the chest
- Fainting, weakness, or dizziness with activity
- Sensation of feeling the heart beat (palpitations)
In infants and children, symptoms include:
- Becoming easily tired with exertion (in mild cases)
- Failure to gain weight
- Poor feeding
- Serious breathing problems that develop within days or weeks of birth (in severe cases)
Children with mild or moderate aortic stenosis may get worse as they get older. They also run the risk of developing a heart infection (bacterial endocarditis).
Exams and Tests
The health care provider will be able to feel a vibration or movement when placing a hand over the heart. A heart murmur, click, or other abnormal sound is almost always heard through a stethoscope. There may be a faint pulse or changes in the quality of the pulse in the neck (this is called pulsus parvus et tardus).
Blood pressure may be low.
The following tests may be performed:
- Chest x-ray
- Doppler echocardiography
- ECG
- Exercise stress testing
- Left cardiac catheterization
- MRI of the heart
- Transesophageal echocardiogram (TEE)
Treatment
If there are no symptoms or symptoms are mild, you may only need to be monitored by a health care provider. Anyone with aortic stenosis should be monitored with a health history, physical exam, and an echocardiogram (heart ultrasound).
People with severe aortic stenosis are usually told not to play competitive sports, even if they don't have symptoms. If symptoms do occur, strenuous activity must be limited.
Medications are used to treat symptoms of heart failure or abnormal heart rhythms (most commonly atrial fibrillation). These include diuretics (water pills), nitrates, and beta-blockers. High blood pressure should also be treated. If aortic stenosis is severe, this treatment must be done carefully so blood pressure does not drop to dangerously low levels.
In the past, most patients with heart valve problems were given antibiotics before dental work or an invasive procedure such as colonoscopy. The antibiotics were given to prevent an infection of the damaged heart.
However, antibiotics are now used much less often before dental work and other procedures. Check with your health care provider to find out whether you need antibiotics.
Patients should stop smoking and be treated for high cholesterol.
Surgery to repair or replace the valve is the preferred treatment for adults or children who develop symptoms. Even if symptoms are not very bad, the doctor may recommend surgery based on test results.
A less invasive procedure called balloon valvuloplasty may be done instead of surgery.
- A balloon is placed into an artery in the groin, threaded to the heart, placed across the valve, and inflated. However, narrowing often occurs again after this procedure.
- A newer procedure done at the same time as valvuloplasty can implant an artificial (prosthetic) valve. This procedure is usually done only in patients who cannot have surgery.
Some children may need aortic valve repair or replacement. Children with mild aortic stenosis may be able to participate in most activities and sports.
Outlook (Prognosis)
Without surgery, a person with aortic stenosis who has angina, fainting (syncope), or signs of heart failure will usually do poorly.
Aortic stenosis can be cured with surgery. After surgery there is a risk for irregular heart rhythms, which can cause sudden death, and blood clots, which can cause a stroke. There is also a risk that the new valve will develop problems (become narrowed or leaky) and will need to be replaced.
Possible Complications
- Angina (chest pain)
- Arrhythmias
- Endocarditis
- Fainting (syncope)
- Left-sided heart failure
- Left ventricular hypertrophy (heart wall thickening) caused by the extra work of pushing blood through the narrowed valve
When to Contact a Medical Professional
Call your health care provider if you or your child has symptoms of aortic stenosis. For example, call if you or your child has a sensation of feeling the heart beat (palpitations) for more than a short period of time.
Also contact your doctor immediately if you have been diagnosed with this condition and your symptoms get worse or new symptoms develop.
References
Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr., Faxon DP, Freed MD, et al; 2006 Writing Committee Members; American College of Cardiology/American Heart Association Task Force. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008;118:e523-e661.
Carabello BA. Valvular heart disease. In: Goldman L, Schafer AI, eds. Cecil Medicine. 24th ed. Philadelphia, Pa: Saunders Elsevier; 2011:chap 75.
Nishimura RA, Carabello BA, Faxon DP, et al. ACC/AHA 2008 guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;52(8):676-685.
Otto CM, Bonow RO. Valvular heart disease. In: Bonow RO, Mann DL, Zipes Dp, Libby P, Braunwald E, eds. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 9th ed. St. Louis, Mo: WB Saunders; 2011:chap 66.
Reviewed By: David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine; and Michael A. Chen, MD, PhD, Assistant Professor of Medicine, Division of Cardiology, Harborview Medical Center, University of Washington Medical School, Seattle, Washington. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M. Health Solutions, Ebix, Inc.
