Aortic Valve Stenosis

What causes aortic stenosis?

The aortic valve is one of four valves found in your heart. This particular valve is the last of the four that blood flows through before being pumped out to your body. The aortic valve normally has three flaps, called leaflets, which open to let blood pass through and seal shut to keep blood from flowing backward into the last chamber.

When not enough blood is flowing through the aortic valve, this is called insufficiency. In some cases, the valve itself can't seal itself shut, causing some blood to flow the wrong way. This is called regurgitation. Either of these problems means too much blood stays in the last chamber of the heart. This increases pressure in that chamber, making your heart work harder than it should and possibly damaging the heart itself.

Aortic stenosis in adults has three main causes:

Wear and tear due to age: Over time, calcium can build up on the valve — similar to what cholesterol does to blood vessels with atherosclerosis — limiting blood flow. Lifestyle habits are also affected if and when stenosis occurs. This type of stenosis happens most commonly after age 65.

Damage from infections: When bacteria from untreated infections reach your bloodstream, they can accumulate on your heart valves, causing your immune system to damage the valve itself. This is most likely to happen with strep throat or scarlet fever, which, when untreated, can cause a condition called rheumatic fever. This disease, which can damage your heart valves, is most often seen in those over 50. It may take years or decades before the damage to your heart valves becomes apparent.

Caused by other inherited or chronic conditions. Other rare conditions that can cause aortic valve stenosis are Paget’s disease of the bone, kidney failure and familial hypercholesterolemia. Aortic stenosis is also linked to autoimmune or inflammatory diseases like lupus and rheumatoid arthritis.

What are the symptoms of aortic stenosis?

Symptoms of aortic stenosis (progressing from less to more severe) include:

Fatigue, especially when it disrupts your normal activities or happens during activities that didn’t tire you out before.

Heart palpitations (where you become unpleasantly aware of your own heartbeat).

Swelling in your feet, ankles or lower legs.

Chest pain (angina). This can also feel like squeezing, pressure or discomfort and it can extend from your chest to your neck, jaw, arm or abdomen.

Shortness of breath.

Dizziness, lightheadedness or fainting.

How fast does the condition progress?

For some people, aortic stenosis can happen slowly and take several years. For others, it can happen much faster. Waiting too long can result in heart damage that can’t be repaired or reversed. In cases of severe aortic stenosis, there’s also a risk of dying suddenly. Because of this, your healthcare provider may advise you not to delay treatment.

How is aortic stenosis diagnosed?

Your primary care provider may refer you to a cardiologist if they suspect you have aortic stenosis. A cardiologist will typically diagnose this condition based on your symptoms (if you have them) and one or more of the following diagnostic tests:

Physical exam. Your doctor may look for swelling in your lower legs and ankles, and will also listen to your heart sounds. Doctors can often hear a heart murmur, a key sign of aortic stenosis, using a stethoscope.

Electrocardiogram (ECG or EKG). This measures the electrical activity of your heart using sensors attached to the skin of your chest.

Chest X-ray, angiography or cardiac CT scan. Each of these methods uses X-rays to see inside your body. CT images also use a computer to help enhance the picture. An angiogram or cardiac CT test also uses contrast, a type of dye visible on an X-ray or CT. Contrast allows specialists to see the structure of the heart and surrounding blood vessels.

Echocardiogram. This test uses ultrasound waves to give healthcare providers a picture of the inside of your heart. A specialized type of echocardiogram is a transesophageal echocardiogram. This uses a device inserted into your mouth and down your esophagus (which passes right behind your heart). This method lets providers see your heart from a closer viewpoint compared to an echocardiogram that is on top of your chest to help see your heart structures and surrounding blood vessels from the inside of your body.

Exercise stress testing. This test measures your heart function while you are active. This test can help determine if you have aortic valve stenosis and how severe your case is.

Cardiac catheterization. Using a device inserted into one of your arteries (usually the femoral artery near the groin) and threaded up to your heart, a specialist can see inside your heart and determine if you have aortic stenosis. They can also measure how well your heart is functioning if they do see stenosis.

Heart MRI: This imaging method provides detailed scans of your heart. Rather than using radiation as an X-ray or CT, an MRI uses an extremely powerful magnetic field to create images of the inside of your body.

Can aortic stenosis be cured?

It's possible to treat or even repair aortic stenosis, depending on when it’s found and what method is used. If you have stenosis but no symptoms, your healthcare provider may advise you to simply monitor the issue with follow-up visits and tests. If you develop symptoms, your provider can offer you treatment options, including the following:

Medication: Several different types of medication — including blood thinners, medications to treat heart rhythm disorders, and more — are often used to treat milder cases of aortic valve stenosis.

Valve repair: Valve repair can be done surgically using either aortic valve surgery or balloon valvuloplasty. During aortic valve surgery — using either a traditional or a minimally invasive approach — a surgeon makes an incision in your chest to directly reach and repair the valve. Balloon valvuloplasty is used in cases with limited damage with limited regurgitation. During this procedure, a catheter with a balloon attached to it can be inserted into one of your arteries and then threaded up to your heart. Once there, the balloon can be inflated to widen the narrowed aortic valve. This is used less often in older people but may help improve symptoms for people with critical stenosis until they can have their valve replaced.

Valve replacement: In cases where valve repair is not indicated, valve replacement is an option. This can be done using a variety of methods. Aortic valve surgery like the repair procedure mentioned above, this procedure replaces the valve in question rather than repairing it. The valve can be replaced with a donor valve (usually from an animal such as a cow or pig), a mechanical valve or a bioprosthetic valve. Another option is a Ross procedure which uses your own pulmonary valve to replace the damaged aortic valve. A donor valve is then used to replace your pulmonary valve. Finally, a Transcatheter aortic valve replacement (TAVR) allows the replacement of an aortic valve without surgery. A catheter-based device is inserted into an artery and then threaded to your heart. In some cases, a “valve-in-valve” approach can place the new valve directly over top of the old one.

What types of replacement valves are there, and why choose one over the others?

Human donor valve: These valves come from organ and tissue donors and are frozen until needed. Donor valves are a good option if you can’t or don’t want to take blood-thinning medications for a long time. However, the donor valve will ultimately wear out and need replacement after about 15 to 20 years.

Animal valve: These are made from animal tissue, usually pigs or cows. These are also a good option if you want to avoid taking blood-thinning medications and last about 15 to 20 years.

Mechanical valve: These valves are often composed of pyrolytic carbon (which is similar to diamonds but with a different structure). These are extremely durable and easily accepted by your body. Some of these valves also have polyester knit fabric around their edges. If you have one of these valves placed, you will need to take blood thinners for the rest of your life to prevent problems like stroke. These valves are made to last for the rest of your lifetime.

Bioprosthetic valve: These valves often combine animal tissue and artificial parts. The animal tissue is usually attached to a metal frame, which keeps the valve in place. These valves typically last about 15 to 20 years.

What else can I do to manage aortic stenosis?

Your healthcare provider can help guide you through what you can do to manage aortic stenosis. For those with no symptoms or mild stenosis, monitoring routine echocardiograms and regular follow-up may be all that’s needed.

For those with moderate aortic stenosis, in addition to monitoring symptoms and routine echocardiograms your healthcare provider may tell you to take it easy on your heart and limit how active you are. They may also have you take medications to prevent clotting or to treat other issues related to aortic stenosis. Once you are diagnosed with severe aortic stenosis, however, you should be referred for evaluation for aortic valve replacement or repair

Depending on the treatment used, you may need to take medication either temporarily or permanently. Your healthcare provider can explain what medications you’ll need to take, how you should take them and for how long.

How long does it take to recover from this treatment?

Recovery from aortic valve stenosis repair or replacement depends on the method used. Surgical methods take the longest. People who have surgery are typically in the hospital for several days, with full recovery usually taking several weeks.

Transcatheter methods like balloon valvuloplasty and TAVR have shorter recovery times. In some cases, people who have these types of procedures can go home either the same day or the next day and resume their everyday lives shortly after.