Aortic valve stenosis is a narrowing of the heart valve, which is located between the aorta of the left ventricle, the aortic valve. It is the most common heart valve defect in Germany. One consequence of the disease is usually an overload of the left heart, which initially leads to an enlargement of the heart muscle (hypertrophy) and finally to heart failure (Heart failure) leads.
There are some characteristic symptoms of aortic valve stenosis, although these usually only appear at an advanced stage. A doctor can use imaging techniques to diagnose aortic valve stenosis. Depending on the stage of the disease, both conservative and surgical treatment options are possible.
While in children and adolescents mostly congenital malformations or acute illnesses are the cause of the stenosis (Narrowing) are mostly so-called in adults degenerative processes, in German a wear and tear, responsible for the aortic valve stenosis. This means that different processes in the body can lead to a more or less severe loss of function of the aortic valve. As a rule, changes to the vessels and the valve in the context of arteriosclerosis are the reason for the development of the aortic valve stenosis. This is a calcification of the vessels and the aortic valve, the cause of which has not yet been fully clarified. However, genetic predisposition and eating habits as well as stimulants (e.g. smoking) are suspected to be mainly responsible for the changes.
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Symptoms often only appear in the late course of the aortic valve stenosis.The human body can compensate for a slight narrowing of the aortic valve, which is why low-grade aortic valve stenoses rarely become symptomatic in everyday life. The most common symptoms include:
- Chest tightness / angina pectoris
- Heart failure
- Atrial fibrillation
- Pulmonary edema
Severe narrowing of the aortic valve is often associated with heart failure and can cause characteristic symptoms. For example, it can lead to a loss of consciousness (Faint) and dizziness attacks. Difficulty breathing and chest or lower jaw pain are also important indicators of the presence of aortic valve stenosis.
A dry cough, rattling noises when breathing, an increased breathing rate and water retention can also represent symptoms of aortic valve stenosis.
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Dizziness can be one of the early signs of aortic valve stenosis. The narrowing caused by the aortic valve stenosis results in less blood flow. As a result, among other things, the brain is undersupplied and it comes to dizziness and sometimes syncope, i.e. a short loss of consciousness. These symptoms occur mainly during physical exertion, as the arteries are opened wide to supply the muscles with enough oxygen, but at the same time the blood pressure drops.
Angina pectoris is sudden chest pain. These occur when the blood flow to the heart is reduced or completely absent. With aortic valve stenosis, the heart has to contract harder due to the narrowing of the aorta in order to expel enough blood. This causes the heart muscle to grow (hypertrophy) and therefore requires more oxygen and thus a higher blood supply. This can lead to an undersupply and thus to angina pectoris even in healthy coronary arteries.
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Heart failure, also known as heart failure, means that the heart is no longer able to pump the blood volume required by the body per minute into the circulation. Various symptoms can then occur, such as Shortness of breath, dizziness, increased drowsiness, cough or pulmonary edema. Cardiac insufficiency occurs with aortic valve stenosis because the heart, through the constriction, has to pump against greater resistance and the muscle of the left ventricle grows. This allows it to counter the higher resistance. After a while the chamber expands (Dilation) However, due to the high pressure and the pumping power drops. Then it comes to heart failure.
Arrhythmias, i.e. cardiac arrhythmias such as atrial fibrillation, can occur in particular with severe aortic valve stenosis. Due to the increased pressure, the left heart grows and expands. This constant strain on the left ventricle leads to atrial fibrillation. With atrial fibrillation, the risk of thrombus formation increases, and therefore the risk of suffering a stroke. Therapy is carried out by removing the aortic valve stenosis. In addition, blood-thinning medication is given to reduce the risk of stroke, and in some cases a pacemaker is inserted.
also read: Symptoms of atrial fibrillation
Pulmonary edema is a complication of aortic valve stenosis. The increased pressure in the heart leads to an enlargement of the left ventricle and ultimately heart failure. Since the heart can no longer effectively supply the body with blood, fluid retention occurs. So fluid accumulates in tissues and organs because not enough is excreted. This accumulation of fluid is called edema. On the one hand, these occur on the legs or in the abdomen. On the other hand, also in the lungs. Symptoms of pulmonary edema include shortness of breath, coughing, foamy sputum, increased heart rate, blue skin (especially lips) and restlessness to the point of fear of death. Pulmonary edema can be life-threatening and therefore requires treatment as soon as possible.
Enlargement of the heart
Aortic stenosis is a narrowing in the outflow area of the left ventricle. This narrowing leads to increased pressure which the left ventricle has to overcome in order to be able to pump the blood into the circulation. Over time, the heart muscle in the left ventricle grows. This allows the stenosis to be compensated. However, the increased pressure is too much for the heart in the long term and the left ventricle becomes enlarged due to dilation (enlargement). As a result, the heart's pumping capacity drops and it leads to heart failure. The heart can no longer eject the amount of blood it needs to effectively supply the body. Symptoms such as edema, shortness of breath or tiredness occur.
More on this: Heart muscle thickening
The therapy for aortic valve stenosis depends on the severity of the disease, the symptoms and any accompanying diseases and the general condition of the patient.
While in mild to moderate aortic valve stenosis without symptoms it is controversial whether the surgical replacement of the aortic valve is justified, surgical procedures for replacing the aortic valve are recommended in moderate to severe and critical aortic valve stenoses. Surgical interventions are also carried out in relatively old patients, as it has been shown that valve replacement can significantly improve the quality of life even in very old patients.
Both artificial and biological (pig) aortic valves can be used for an aortic valve replacement. With the help of new surgical techniques, under certain conditions it is possible to insert the new aortic valve with the help of a catheter using this keyhole technique in a minimally invasive way.
Drug therapy is only recommended if surgical therapy is not possible for certain reasons.
Medication for aortic stenosis
There is currently no drug therapy for the successful treatment of aortic valve stenosis and, according to the current state of research, is not expedient. Studies have shown that the progression of the disease cannot be slowed down by drug therapy.
Above all, it is important that risk factors are minimized and, if necessary, a lifestyle change is made. However, due to the late diagnosis, surgical therapy is the only way for most patients to successfully treat the disease.
An exception are patients who, due to other risk factors or concomitant diseases, cannot have aortic valve replacement or have to wait for the procedure. Medicines such as diuretics, ACE inhibitors, digoxin or so-called "sartans" can be used here. These drugs are generally aimed at making the heart easier to pump. In order not to jeopardize the success of the therapy, regular check-ups should take place in these cases.
Surgery for aortic stenosis
According to current research, surgical intervention is the only way to successfully treat aortic valve stenosis. Depending on the patient's condition and the requirements of the hospital, different surgical procedures can be considered. Open surgery is performed for patients who can be expected to undergo an operation due to any accompanying illnesses and their general condition. In this open operation, the old aortic valve is removed and either an artificial or a biological heart valve is sewn into the heart.
It is also possible to insert the heart valve using a catheter. With this one, also as TAVI (transcatheter aortic valve implantationprocedure, the new biological heart valve is guided via an artery on the groin with the aid of a catheter to the aortic valve and at this point pressed into the old, narrowed valve. At present, this procedure is only performed on patients for whom open surgery would be too risky.
When do you need an operation?
During an aortic valve stenosis operation, the valve is replaced with a prosthesis. This is indicated when symptoms, especially heart failure, occur. Even if there are no complaints, but there is a pressure difference of over 50 mmHg between the left ventricle and the aorta. Because life-threatening arrhythmias can also occur here.
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When is a catheter procedure performed?
An alternative to the surgical procedure is a so-called TAVI (Transapical Valve Implantation). The replacement flap is folded up and inserted over the groin via a catheter. When you reach the old aortic valve, it is expanded by balloon and the new valve is pressed into its place. This procedure is much gentler than surgery, as the chest cavity does not have to be opened and the heart does not have to be stopped. Because this is a relatively new method of aortic valve replacement, there is not as much long-term experience as with the operation. Studies are also still pending on the durability of the latest generation of valves, so no definitive statement can be made.
Guidelines for the therapy of aortic valve stenosis
The last valid guideline, which deals among other things with the treatment and diagnosis of aortic valve stenosis, was published by the "European Society of Cardiology“Written. As part of the new methods of surgical aortic valve replacement, many experts have dealt with this new guideline, which was published in 2012.
The main components of the guidelines are the indications for which surgical intervention or conservative therapy is recommended, as well as the framework conditions that must be in place for performing the surgical intervention, as well as contraindications for which the respective therapy should not be carried out.
The guideline also provides an overview of the study results for individual therapy options. While the guideline is taken into account in Germany in the indication for surgical interventions, individual deviations may be necessary.
Since the guideline was published, a TAVI (transcatheter aortic valve implantation), however, only possible in certain specially equipped hospitals.
What are the life expectancies with aortic stenosis?
Aortic valve stenosis is often an incidental finding because the heart adapts and it is possible that even with a severe form there is little or no discomfort. It may be that the valve narrowing increases only very slightly or not at all over the years. Therefore, the life expectancy of a sick patient must always be considered individually. However, one can make statements about the average life expectancy if the symptoms are left untreated. If angina pectoris (chest tightness) occurs, that would be about 5 years. Syncope (short-term loss of consciousness) reduces the average life expectancy to about 3 years and in the case of heart failure with pulmonary congestion or pulmonary edema, untreated, an average of 2 years can be expected. In general, the earlier you start therapy, the less damage it will do to the heart and the better your life expectancy.
Since the symptoms of aortic stenosis often only appear in the late stages of the disease, the diagnosis of aortic stenosis is often made relatively late. In addition to questioning the patient (anamnese) and the physical examination, the attending physician can listen to the heart with a stethoscope to make the diagnosis. Changes in flow that indicate aortic valve stenosis, so-called heart murmurs, can often be heard here.
The best way to diagnose aortic valve stenosis is through imaging tests. In particular, the examination with an ultrasound device is often used to diagnose the disease. In this case one speaks of echocardiography.
ECG examinations and X-rays, which can be used to show the consequences of aortic valve stenosis, are also relevant.
Heart echo / echocardiography
The heart ultrasound underestimation is used by doctors as echocardiography, Heart echo or often briefly "echo"and is the so-called gold standard when it comes to diagnosing aortic valve stenosis. Gold standard means that an examination is generally considered the best diagnostic method for the respective disease, and all other methods must be measured against this.
This ultrasound examination of the heart can make the heart and the heart valves visible either through the esophagus or from the outside through the chest, and thus serves to reliably diagnose the disease.
The so-called "Schluckecho" (Transesophagal echocardography, TEA), which is carried out through the esophagus with the help of a flexible tube, is usually carried out under a light anesthetic. The diameter of the flap can be measured on the monitor of the device. If the aortic valve is narrowed, the diameter is significantly reduced. The thickness of the muscle of the left ventricle can also be measured, which is often massively increased in the case of an aortic valve stenosis.
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Eavesdropping on the heart and heart murmurs
During the physical examination, in addition to other measures, the doctor will listen to the heart. The aortic valve stenosis is often noticed by a characteristic heart murmur, which is triggered by the narrowing in the area of the valve. This heart sound is described as a spindle-shaped mesosystolic, which can be heard particularly well between the second and third ribs. Spindle-shaped means that the sound starts softly, then gets louder and then quieter again towards the end, like the shape of a spindle. Mesosytolic means that the sound begins in the middle of the systole, i.e. in the phase in which the heart chambers contract and the blood is pumped into the circulation. In some cases you can hear a click before the actual heart murmur begins (Ejection click).
Division into degrees of severity
The classification of aortic valve stenosis into degrees of severity is handled differently. The classification presented below represents the most common classification in Germany.
The grading of the aortic valve stenosis ranges from light to medium to severe and critical. In order to differentiate between these degrees of severity, three criteria are generally used.
The first criterion is the so-called mean systolic pressure gradient. Since the narrowing of the aortic valve reduces the transition from the left ventricle to the aorta, the pressure that arises in the ventricle and in the aorta behind the aortic valve is not the same.
Depending on how severe the stenosis is, the higher the pressure gradient. The pressure gradient becomes like the blood pressure in the unit mmHg specified. While a slight stenosis has a pressure gradient of up to 25 mmHg, with a medium stenosis it is between 25 and 40 mmHg. A severe stenosis is when the pressure gradient is over 40 mmHg. Critical aortic valve stenosis is when the pressure gradient is above 70 mmHg.
The second criterion that is used in the grading of the aortic valve stenosis is the measured valve opening area (KÖF). This is usually measured using a heart echo and expressed in the unit "cm²“Stated.
The smaller the valve opening area, the more severe the aortic valve stenosis. While a valve opening area of over 1.5 cm² is referred to as a mild stenosis, the area of a moderate stenosis is between 1 and 1.5 cm². If the valve opening area is less than 1.0 cm², one speaks of a severe stenosis. A very critical aortic valve stenosis is when the valve opening area is less than 0.6 cm².
The third criterion for assessing the severity is the patient's symptoms. While mild aortic stenosis is always accompanied by no symptoms and moderate stenosis is usually asymptomatic, severe aortic stenosis usually shows the typical symptoms of the disease.A very critical stenosis almost always shows symptoms. (so.)
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- Heart anatomy
- Aortic valve anatomy
- Right atrial -
- Right ventricle -
- Left atrium -
- Left ventricle -
- Aortic arch - Arcus aortae
- Superior vena cava -
Superior vena cava
- Lower vena cava -
Inferior vena cava
- Pulmonary artery trunk -
- Left pulmonary veins -
Venae pulmonales sinastrae
- Right pulmonary veins -
Venae pulmonales dextrae
- Mitral valve - Valva mitralis
- Tricuspid valve -
- Chamber partition -
- Aortic valve - Valva aortae
- Papillary muscle -
You can find an overview of all Dr-Gumpert images at: medical illustrations
Since the symptoms of aortic valve stenosis often appear very late, the prognosis of the disease without the surgical replacement of the valve is relatively poor, since the disease is well advanced at the time of diagnosis.
The individual prognosis is significantly influenced by the severity of the stenosis, but also by the general condition and any prevailing accompanying diseases. The ability to replace the aortic valve has significantly improved the prognosis of the disease. It is assumed that especially older patients will reach about the same age after valve replacement as people in their age group without aortic valve stenosis.