Fast Five Quiz: Heart Valve Disease

Yasmine S. Ali, MD, MSCI


April 22, 2020

Aortic stenosis is the obstruction of blood flow across the aortic valve. It usually has an asymptomatic latent period of 10-20 years. Severe aortic stenosis is rare in infancy and is due to a unicuspid or bicuspid valve. Most patients with a congenitally bicuspid aortic valve who develop symptoms do not do so until middle age or later. Patients with rheumatic aortic stenosis typically present with symptoms after the sixth decade of life.

Exertional dyspnea is the most common initial symptom, even in patients with normal LV systolic function, and it often relates to abnormal LV diastolic function. In addition, patients may develop exertional chest pain, effort dizziness or lightheadedness, easy fatigability, and progressive inability to exercise. Ultimately, patients experience one of the classic triad of chest pain, heart failure, and syncope.

Diagnostic studies in the emergency department should include ECG, chest radiography, serum electrolyte levels, cardiac biomarkers, and a complete blood cell count. Arterial blood gas measurements are generally not necessary but may be obtained if hypoxemia or a mixed respiratory disease state is suspected.

Two-dimensional transthoracic echocardiography can confirm the clinical diagnosis of aortic stenosis and provide specific data on LV function. The etiology of aortic stenosis (bicuspid, rheumatic, or degenerative calcific) may be assessed from the two-dimensional echocardiographic, parasternal, short-axis view. The structure and function of the other heart valves can also be assessed.

The following echocardiographic findings are indicative of severe aortic stenosis:

  • An echo-dense aortic valve with no cusp motion (may be unreliable in congenital or rheumatic valvular stenosis)

  • A decrease in the maximal aortic cusp separation (< 8 mm in the adult)

  • Mean transvalvular gradient ≥ 40 mm Hg

  • Valve area < 1 cm2

  • Peak aortic jet velocity > 4 m/s

  • The presence of otherwise unexplained LV hypertrophy

The only definitive treatment for aortic stenosis in adults is aortic valve replacement, performed surgically or percutaneously. The development of symptoms due to aortic stenosis is a clear indication for replacement. For patients who are not candidates for aortic replacement, percutaneous aortic balloon valvuloplasty may provide some symptom relief.

In 2017, the first document to address appropriate use criteria for the treatment of severe aortic stenosis was released. Among the recommendations, asymptomatic patients with high-gradient severe aortic stenosis may not require intervention. Intervention may be considered in asymptomatic patients with an LV ejection fraction ≥ 50% and Vmax of 4.0-4.9 m/sec.

Read more about aortic stenosis.


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