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    Aortic Valve Stenosis

    Aortic Valve Stenosis

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    Topic Overview

    The heart

    What is aortic valve stenosis?

    Aortic valve stenosis is a narrowing of the aortic valve . The aortic valve allows blood to flow from the heart's lower left chamber (ventricle) into the aorta and to the body. Stenosis prevents the valve from opening properly, forcing the heart to work harder to pump blood through the valve. This causes pressure to build up in the left ventricle and thickens the heart muscle.

    Your heart can make up for aortic valve stenosis and the extra pressure for a long time. But at some point, it won't be able to keep up the extra effort of pumping blood through the narrowed valve. This can lead to heart failure .

    What causes aortic valve stenosis?

    Problems that can cause aortic valve stenosis include:

    • Calcium buildup on the aortic valve. As you age, calcium can build up on the valve, making it hard and thick. This buildup happens over time, so symptoms usually don't appear until after age 65.
    • A heart defect you were born with (congenital).
    • Rheumatic fever or endocarditis . These infections can damage the valve.

    What are the symptoms?

    Aortic valve stenosis is a slow process. For many years, even decades, you will not feel any symptoms. But at some point, the valve will likely become so narrow (often one-fourth of its normal size) that you start having problems. Symptoms are often brought on by exercise, when the heart has to work harder.

    As aortic valve stenosis gets worse, you may have symptoms such as:

    • Chest pain or pressure ( angina ). You may have a heavy, tight feeling in your chest.
    • Feeling dizzy or faint.
    • Feeling tired and being short of breath.
    • A feeling that your heart is pounding, racing, or beating unevenly ( palpitations ).

    If you start to notice any of these symptoms, let your doctor know right away. If you have symptoms, your doctor will likely recommend a valve replacement. By the time you have symptoms, your condition probably is serious. If you have symptoms, you also have a high risk of sudden death.

    How is aortic valve stenosis diagnosed?

    Most people find out they have it when their doctor hears a heart murmur during a regular physical exam. To be sure of the diagnosis, your doctor may want you to have an echocardiogram , which can show moving pictures of your heart. You may have other tests to help your doctor judge how well your heart is working.

    How is it treated?

    If you have mild or moderate aortic valve stenosis and you don't have symptoms, your doctor will see you regularly to check your heart. You probably will not have surgery until your stenosis is severe or until the benefits of surgery outweigh the risks.

    If you have severe stenosis, you probably need a valve replacement. Valve replacement is typically done during open-heart surgery. View a slideshow on aortic valve replacement surgery . Some young people or pregnant women may have another procedure called balloon valvuloplasty to enlarge the valve opening. Some people who cannot have open-heart surgery may have a minimally invasive procedure to replace the valve.

    If you have severe stenosis but don't have your valve replaced, you have a high risk of dying suddenly or developing heart failure. Replacing your valve can help you have a more normal life span and improve your quality of life.

    Your doctor will probably recommend some lifestyle changes to keep your heart healthy. He or she may advise you to:

    • Quit smoking and stay away from secondhand smoke.
    • Follow a heart-healthy diet and limit sodium.
    • Be active. Ask your doctor what level and type of exercise is safe for you. You may need to avoid intense activity.
    • Stay at a healthy weight, or lose weight if you need to.

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    Cause

    Most people who have aortic valve stenosis are born with a normal, healthy aortic valve but develop aortic stenosis late in life. Aging and calcium buildup cause the leaflets of the valve to thicken and harden, preventing the valve from opening properly. Typically, stenosis develops slowly over many years.

    Most young people and teens who have aortic valve stenosis developed it from a congenital heart defect. The most common heart defect that causes aortic stenosis is a bicuspid aortic valve .

    Some people may develop aortic stenosis after having rheumatic fever.

    Symptoms

    You probably won't have any symptoms if you have mild or moderate aortic valve stenosis, because your heart can make up for the stenosis. You may begin to notice symptoms if the pressure buildup in the heart becomes severe or if blood flow to the heart and the rest of the body is reduced. You may have symptoms when you exercise or do something strenuous, because your heart has to work harder.

    Symptoms may include:

    • Chest pain or pressure ( angina ), often described as a heavy, tight feeling in your chest. You may also have a burning, choking, or constricting feeling that may spread to your arms, shoulders, or neck.
    • Dizziness, fainting, or loss of consciousness.
    • Signs of heart failure , such as fatigue and shortness of breath with activity.
    • Palpitations (an uncomfortable feeling that your heart is beating rapidly or irregularly).

    What Increases Your Risk

    Certain medical problems or conditions make it more likely that you will develop aortic valve stenosis:

    • Calcium buildup. Aging can cause calcium buildup around the aortic valve, which can make the normally thin and flexible valve flaps thick and stiff. This is also called calcific aortic valve stenosis. Many of the things that increase the risk of atherosclerosis and heart disease are the same for aortic valve stenosis. They include smoking, high cholesterol , high blood pressure , diabetes , and being male.
    • Birth defect. Sometimes a person is born with a bicuspid aortic valve that has two flaps instead of the normal three. Over time, the valve becomes damaged and calcium builds up. As the valve narrows, less blood can flow through it.
    • Infection. Rheumatic fever can cause scar tissue to build up at the edges of the valve. Rheumatic fever is not common now. But if you had it as a child, your risk of aortic valve stenosis may be increased.
    • Artificial valve. Aortic valve disease also may develop in an artificial aortic valve that is made from human or animal tissue.

    Other things that increase the risk for aortic valve stenosis include:

    • Kidney failure.
    • Smoking.

    When to Call a Doctor

    Call your doctor immediately if you have any of the symptoms of aortic valve stenosis , such as:

    • Chest pain or pressure.
    • Fainting.
    • Shortness of breath.
    • Palpitations (feeling like your heart is pounding or racing).

    Who to see

    Your family doctor may diagnose aortic valve stenosis during a routine checkup. Other health professionals who also may discover aortic valve stenosis during a physical exam include:

    Exams and Tests

    Physical exam

    A physical exam and review of your medical history are important first steps in diagnosing aortic valve stenosis. If you have stenosis but no symptoms, your doctor will likely find the condition during a routine exam or a checkup for another health problem. A distinctive heart murmur is usually the first clue that leads a doctor to suspect aortic valve stenosis.

    During the physical exam, the doctor will:

    • Take your blood pressure. Low blood pressure may mean that not enough blood is getting through the narrowed aortic valve.
    • Check your pulse. A weak pulse may mean that there is narrowing of the heart valve.
    • Listen to your heart and lungs for abnormal sounds. A soft whooshing or humming sound (murmur) heard through a stethoscope is an important finding that often points to heart valve disease. Abnormal sounds in the lungs can mean fluid buildup in the lungs that is caused by heart valve disease.
    • Look at your legs and feet. Swelling in the legs and feet may be a sign of heart failure .

    Echocardiogram

    An echocardiogram (echo) can confirm your symptoms and tell your doctor how severe stenosis is, how well your left ventricle is working, and whether there are problems with other valves.

    It's also an important test to help monitor aortic valve stenosis over time.

    Recommended frequency for checking aortic valve stenosis 1
    Severity of aortic valve stenosis How often you should have an echocardiogram

    Mild

    Every 3 to 5 years

    Moderate

    Every 1 to 2 years

    Severe

    Every 6 to 12 months

    Other tests for aortic valve stenosis

    • Stress echocardiogram. This test can show how severe your aortic valve stenosis is.
    • Electrocardiogram (EKG or ECG). This test may show abnormalities in heart rhythm or lower left heart chamber (ventricle) thickness.
    • Exercise electrocardiogram. This test may be done to see how the heart responds to exercise.
    • Chest X-ray. It may show calcium buildup in the valve, an enlarged left ventricle, or fluid buildup if you have developed heart failure. In some cases, the aorta may be enlarged just beyond the aortic valve.
    • Brain natriuretic peptide (BNP) test. This test may help show how well your heart is working and if you have heart failure.
    • Cardiac catheterization. This test may be done to check the valve or check blood pressure in the heart chambers.

    Treatment Overview

    Treatment for aortic valve stenosis is replacement of the aortic valve.

    Valve replacement is recommended based on many things including how severe the stenosis is, whether you have symptoms, and how well your heart is pumping blood. It is typically recommended when a person has severe stenosis. If you have severe stenosis, especially with symptoms, surgery to replace the aortic valve is usually required. If you don't have your valve replaced after your stenosis is severe, you have a high risk of dying suddenly or developing heart failure. Valve replacement can relieve symptoms, improve your quality of life, and help you have a more normal life span.

    View a slideshow on aortic valve replacement surgery . For more information, see Surgery.

    Click here to view a Decision Point. Aortic Valve Stenosis: Should I Have Surgery?

    Balloon valvuloplasty is a less invasive procedure that might be done for some children, teens, or young adults in their 20s, or for people for whom valve surgery is too great a risk. For more information, see Surgery.

    You may need medicine to prevent or treat a heart infection or to help manage heart failure , which is the most common complication of aortic valve stenosis. For more information, see Medications.

    End-of-life care

    Aortic valve stenosis tends to get worse over time. So you need to decide what kind of care you want at the end of your life.

    It can be hard to have talks with your doctor and family about the end of your life. But making these decisions now may bring you and your family peace of mind. Your family won't have to wonder what you want. And you can spend your time focusing on your relationships.

    You will need to decide if you want life-support measures if your health gets very bad. An advance directive is a legal document that tells doctors how to care for you at the end of your life. This care includes electronic devices that are used for heart failure, such as pacemakers. You also can say where you want to have care. And you can name someone who can make sure your wishes are followed.

    For more information, see the topic Care at the End of Life.

    Living With Aortic Valve Stenosis

    How you will feel and how aortic valve stenosis will affect your life will vary greatly depending on whether you have symptoms and the treatment decisions you make. Your doctor will probably suggest lifestyle changes to help keep your heart and body healthy.

    Make healthy lifestyle changes

    • If you smoke, try to quit. Medicines and counseling can help you quit for good.
    • Your doctor will also recommend that you follow a heart-healthy diet and limit how much sodium you eat.
    • Be active, but you might need to avoid strenuous exercise. Physical activity is good for your overall health. But the type of exercise that is appropriate varies depending on how severe your aortic valve stenosis is. If you have mild stenosis, you will not need to restrict your level or type of physical exercise. But if you have severe stenosis, you should avoid strenuous activities such as weight lifting or running. Talk with your doctor about what kinds of exercise are safe for you.
    • Stay at a healthy weight. Lose weight if you need to. For help, see the topic Weight Management.

    Take care of yourself

    • See your doctor right away if you have new symptoms or symptoms that get worse. Symptoms may include chest pain or pressure, fainting, and shortness of breath.
    • See your doctor regularly, and get the tests you need to assess your heart, such as echocardiograms. For more information, see Exams and Tests.
    • Manage other health problems including high blood pressure, diabetes, and high cholesterol.
    • Practice good dental hygiene and have regular checkups. Good dental health is especially important, because bacteria can spread from infected teeth and gums to the heart valves.
    • Get a flu vaccine every year. Get a pneumococcal vaccine shot. If you have had one before, ask your doctor if you need another dose.
    • Talk with your doctor if you have concerns about sex and your heart. Your doctor can help you know if or when it's okay for you to have sex.

    Medications

    Medicines aren't used to treat aortic valve stenosis . But you may need medicines to prevent and treat complications from the condition. Or you may need to take medicines if you have your valve replaced.

    If you have an artificial valve, you may need:

    • Blood thinners. You may take a blood thinner to prevent blood clots. Blood thinners include antiplatelet medicine, such as aspirin, or anticoagulant medicine, such as warfarin.
    • Antibiotics . If you have an artificial valve, you may need these medicines before you have certain dental or surgical procedures. The antibiotics help prevent an infection in your heart called endocarditis .

    You may need other medicines if you develop other problems, such as arrhythmias or heart failure. For more information, see the topic Heart Failure.

    Surgery

    Your doctor will likely recommend valve replacement surgery if you have severe stenosis, especially if you have symptoms, unless you have other health problems that make surgery too risky.

    Aortic valve replacement surgery

    Aortic valve replacement surgery is typically an open-heart surgery. In an aortic valve replacement surgery, the damaged valve is removed and replaced with an artificial valve (mechanical or tissue).

    View a slideshow on aortic valve replacement surgery .

    To learn more about this decision, see:

    Click here to view a Decision Point. Aortic Valve Stenosis: Should I Have Surgery?

    If you decide to have surgery, you and your doctor will decide which type of valve is right for you. For help with this decision, see:

    Click here to view a Decision Point. Heart Valve Problems: Should I Choose a Mechanical Valve or Tissue Valve to Replace My Heart Valve?

    Bypass surgery with valve replacement surgery

    If you are going to have valve replacement surgery, your doctor may suggest that you have a coronary angiogram/catheterization test. This test can show if you have blockages in your coronary arteries (as part of coronary artery disease). If you have serious blockages, your doctor may want to do a coronary artery bypass surgery at the same time as the valve replacement surgery. For more information, see Aortic Valve Stenosis: Treatment with Other Heart Diseases.

    Transcatheter aortic valve replacement

    Transcatheter aortic valve replacement is a new way to replace an aortic valve. It does not require open-heart surgery. It is a minimally invasive procedure that uses catheters in blood vessels to replace the aortic valve with a specially designed artificial valve. This procedure is available in a small number of hospitals. And it is not right for everyone. It might be done for a person who cannot have surgery or for a person who has a high risk of serious problems from surgery.

    Balloon valvuloplasty

    Balloon valvuloplasty is a less invasive procedure than surgery. It may be an option for some people who have aortic valve stenosis. Although the heart valve is not replaced, the narrowed opening is made larger.

    Other Places To Get Help

    Organizations

    National Heart, Lung, and Blood Institute (NHLBI) (U.S.)
    www.nhlbi.nih.gov
    American Heart Association (AHA)
    www.heart.org

    References

    Citations

    1. Nishimura RA, et al. (2014). 2014 AHA/ACC guideline 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. Circulation, published online March 3, 2014. DOI: 10.1161/CIR.0000000000000031. Accessed May 1, 2014.

    Other Works Consulted

    • Freeman RV, Otto CM (2011). Aortic valve disease. In V Fuster et al., eds., Hurst's The Heart, 13th ed., vol. 2, pp. 1692-1720. New York: McGraw-Hill.
    • Nishimura RA, et al. (2014). 2014 AHA/ACC guideline 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. Circulation, published online March 3, 2014. DOI: 10.1161/CIR.0000000000000031. Accessed May 1, 2014.
    • Oakley RE, et al. (2008). Choice of prosthetic heart valve in today's practice. Circulation, 117(2): 253-256.
    • Whitlock RP, et al. (2012). Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic therapy and prevention of thrombosis, 9th ed.-American College of Chest Physicians evidence-based clinical practice guidelines. Chest, 141(2, Suppl): e576S-e600S.

    Credits

    ByHealthwise Staff
    Primary Medical Reviewer Rakesh K. Pai, MD, FACC - Cardiology, Electrophysiology
    Specialist Medical Reviewer David C. Stuesse, MD - Cardiac and Thoracic Surgery

    Current as ofAugust 8, 2014

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