Aortic Stenosis

Exam Cram

• Aortic Stenosis is a narrowing of the aortic valve, within the left ventricle

• Presentation: syncope, angina & dyspnoea (SAD), ejection systolic murmur

• Diagnosis: ECHO

• Management: surgery if symptomatic

Outline

Background

• Most common valvopathy, commonly caused by age related degeneration

• Bicuspid common variant, predisposes to aortic stenosis

• Aortic sclerosis pre-clinical stage

Assessment

History (SAD)

• Syncope

• Angina (chest pain)

• Dyspnoea (short of breath)

Examination

• Ejection systolic murmur radiating to the carotids

• Slow rising pulse, narrow pulse pressure

• Anacrotic pulse (low volume)

Investigations

• ECG: LVH

• ECHO: assess flow gradient & LV function

Diagnosis

Diagnostic criteria: ECHO

Differentials: Mitral regurgitation- pansystolic murmur

Classification: severity markers dictate requirement for operation:

• Symptomatic: syncope, angina, dyspnea

• Valve gradient > 50mmhg

• Evidence of Congestive Heart Failure (CHF) 

Management

Acute decompensation- as per exacerbation of Congestive Heart Failure (CHF) 

Definitive options: 

• Medical management 

• TAVI: transcatheter aortic valve implantation

• Open cardiothoracic surgery

• End of Life Care 

MED Reg Notes

Management Overview

Medical Management

Medical management has limited success with high 5 year mortality with the majority resulting in death or surgery. This can be done whilst watching and waiting, planning surgery or in conjunction with End of Life Care. 

• Caution with betablockers as can reduce heart's ability to overcome narrowing- felt to be cardioprotective if tolerated, start low and go slow

• ACEi well tolerated in severe AS

• Loop duiretics used in caution due to reducing ventricular filling (pre-load)

TAVI is preferred in frail individuals because it has fewer side effects but higher relapse rate. 

Open cardiothoracic surgery is preferred in young individuals who are able tolerate the longer rehab process and benefit from a lower relapse rate. The concern in young patients is that the revision surgery becomes more difficult with each relapse. Aortic dissection, other Cardiac Valvulopathies & Coronary Artery Disease should be considered prior to surgery. 

Pregnancy

• A symptomatic aortic valve is associated with a 10% maternal mortality. 

• Therefore valve replacement is advised prior to pregnancy

Bicuspid Aortic Valve

Background

• Normally the aortic valve has three cusps. A Bicuspid Aortic valve has two (bi = 2). 

• Twice as common in females. 

• Familial - 20% have family member

• Prognosis: No intervention to slow progression, will reliably degenerate

Associated condition Prevalence of bicuspid valve

Coarctation of aorta: 50%

Turner's Syndrome 30%

Ventricular Septal Defect (VSD): 30%

Population 1%

Diagnosis: transthoracic ECHO

• Assess for AS, AR, aortic (root) dilatation

Management

• Screen first degree relatives for arteriopathy

• Monitor & replace as per tricuspid aortic valve indications

• If aortic root > 4.5cm may require aortic root replace as well

Aortic Sclerosis

• Pre-morbid form of aortic stenosis

• 5% progression per year

• Requires no intervention, consider monitoring with ECHO

References

1. Mubarik A, Sharma S, Law MA. Bicuspid Aortic Valve. [Updated 2023 Jan 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534214/

Written in 2025