Aortic valve stenosis is the most common cause of left ventricular outflow obstruction in children and adults.
“An ejection-systolic murmur, heard on the right 2nd ICS, radiating to carotid arteries”
Mitral regurgitation (MR), which is also known as mitral insufficiency, is a common heart valve disorder. When MR is present, blood leaks backwards through the mitral valve when the heart contracts. This reduces the amount of blood that is pumped out to the body.
“A pansystolic murmur, heard on the left 5th ICS, MCL, radiating to the axilla”
Approximately 2% of people over the age of 65, 3% of people over age 75, and 4% percent of people over age 85 have aortic valve stenosis.¹
The prevalence is increasing with the ageing population in North America and Europe.
Degenerative calcific aortic stenosis usually manifests in individuals older than 75 years.
MR affects males and females equally.
2nd most common
Age related degenerative sclerocalcific changes to the valves
Congenital bicuspid aortic valve –e.g. Williams syndrome
Aortic stenosis – Cardiomegaly (enlarged left ventricle) // Calcification of aortic ring
Mitral regurgitation – enlarged left atrium / left ventricle // pulmonary oedema
Allows direct visualisation of valve dysfunction
Can also assess ventricular function/wall thickness
Can assess severity of AS – pressure gradients etc
Trans-oesophageal echo (TOE) should be considered if transthoracic echo doesn’t provide adequate image quality
Can provide more detailed imagery of the heart & valve of interest
It can assess the ascending aorta for pathology
It can help assess valve area & the amount of calcification
Sometimes required to accurately measure pressure gradients across a given valve
Often performed to provide more information about coronary risk, which is important when a patient is being considered for valve replacement.
Symptomatic patients require early surgical intervention because no medical therapy for AS is able to improve outcome.
Modification of atherosclerotic risk factors is strongly recommended. Aortic stenosis in the older age group should be seen as a strong risk for ischaemic heart disease: ²
Antihypertensives – being careful not to induce hypotension
Smoking cessation & dietary advice
If the patient is unsuitable for surgical intervention:
Digoxin / Diuretics / ACE inhibitors – to provide symptomatic relief from heart failure symptoms
Maintenance of sinus rhythm is important – use antiarrhythmic drugs as required
Aortic valve replacement
Aortic valve replacement (AVR) is the definitive therapy for severe AS.
Operative mortality of AVR for AS:
1-3% in patients < 70 years
4-8% in older adults
Early valve replacement is strongly recommended for all symptomatic patients with severe AS who are suitable for surgery.
Transcatheter aortic valve implantation (TAVI)
TAVI is a recent development and provides a method of AVR which does not carry the same risks as surgical AVR mentioned above.
What does TAVI involve?
TAVI can be performed under a general anaesthetic or under local anaesthetic with sedation, making it a consideration in patients who are unsuitable for surgical AVR.
TAVI involves the replacement of the aortic valve of the heart via the blood vessels (not requiring open heart surgery). The replacement valve is delivered via one of several access methods: transfemoral (in the upper leg), transapical (through the wall of the heart), subclavian (beneath the collarbone) and direct aortic (through a minimally invasive surgical incision into the aorta). The whole procedure occurs under fluoroscopy and echocardiography guidance.
The procedure is less invasive and carries fewer risks than a surgical aortic valve replacement.
The procedure is of equal efficacy as surgical AVR in patients who are unsuitable for surgery.
As with any surgical procedure, there are associated risks which include majorbleeding, stroke, arrhythmias, MI, Aortic Dissection and residual aortic regurgitation.
This procedure involves widening of a stenotic aortic valve using a balloon catheter inside the valve. The balloon is inflated in an effort to increase the opening size of the valve and improve blood flow.
Current evidence supports the safety and efficacy of balloon valvuloplasty for aortic valve stenosis in adults and children.³
However, restenosis and clinical deterioration occur within 6-12 months in most patients.³
In adults, the procedure is only used to treat patients who are unsuitable for surgery, due to the efficacy usually being short-lived.
Medical management is non-curative and is indicated in mild to moderate disease, or in those unsuitable for surgery: