Treatment Options in Severe Aortic Stenosis

Case presentation: An 80-year-old woman is referred for cardiovascular evaluation because of a systolic murmur. She denies symptoms of angina, syncope, or heart failure. The physical examination and echocardiogram are consistent with severe aortic stenosis (AS). What further evaluation is indicated?Aortic stenosis is becoming more frequent as the average age of the population increases; it affects up to 5% of the elderly population.1 The diagnosis of severe AS is most easily defined by Doppler echocardiography with maximum aortic jet velocity >4.0 m/s, mean transvalvular pressure gradient >40 mm Hg, and continuity equation valve area <1.0 cm2 or valve area index <0.6 cm2 (Figure 1).2 However, when cardiac output is low, a lower transvalular gradient and jet velocity may be present. Echocardiography is also used in patients with AS to assess left ventricular hypertrophy, size, and function; left atrial size, and the presence of pulmonary hypertension or other associated valvular disease. Nevertheless, the decision to proceed with aortic valve replacement (AVR) is usually based on the presence of symptoms. So, if this patient really is asymptomatic, the echocardiographic criteria for severe AS would not automatically result in a cardiac surgery referral.3–5Figure 1. Management strategy for patients with severe aortic stenosis. AVA indicates aortic valve area; BP, blood pressure; CABG, coronary artery bypass graft surgery; echo, echocardiography; LV, left ventricular; and Vmax, maximal velocity across aortic valve by Doppler echocardiography. Reprinted from Bonow et al2 with permission of the publisher. Copyright © 2008, the American Heart Association.The 1%/y risk of sudden death in asymptomatic patients with AS is not higher than that of historical controls without AS.5 However, because patients may deny or fail to recognize symptoms or avoid them by decreasing physical activity, exercise testing can be useful in asymptomatic …