natural history management aortic stenosis

1. NATURAL HISTORY AND TREATMENT
OF AORTIC STENOSIS
29/FEB/2016

2. AORTIC JET VELOCITY
(m/sec)
MEAN GRADIENT
(mm Hg)
VALVE AREA (cm2)
NORMAL <1.5 <5 3.0-4.0
MILD 2.5-2.9 <20 >1.5
MODERATE 3.0-3.9 20-39 1.0-1.5
SEVERE >4.0 >40 <1.0
CRITICAL/VERY SEVERE >5.0 >60 <0.75
Symptoms in patients with AS
and normal left ventricular
systolic function rarely occur
until the AS is severe.
Many patients do not develop
symptoms until critical valve
obstruction is present, while
others have symptoms when the
stenosis is less severe,
particularly if there is coexisting
aortic regurgitation or systemic
arterial hypertension

3. • In his 1958 Nathanson Lecture, Dr Paul Wood
argued prophetically that “aortic stenosis is a
simple mechanical fault which, if severe
enough, imposes a heavy burden on the left
ventricle and sooner or later overcomes it” .
• The burden of AS on the left ventricle remains
true today, but what has changed is that AS
management is no longer simple.

4. TODAY’S DISCUSSION
SYMPTOMATIC
AS
ASYMPTOMATIC
AS

5. PROGRESSION OF ASYMPTOMATIC AS
• The average rate of increase in the mean systolic
pressure gradient is 4 to 7 mmHg per year, but
some patients show an increase of as much as 15
to 19 mmHg per year.
• Valve area declines at an average rate of 0.1
cm 2 per year, but some patients have little or no
progression and others progress more rapidly.
• Aortic jet velocity increases by an average of
0.3 m/sec per year, but this is also variable

6. • Patients with mild disease (ie, aortic jet velocity
less than 3.0 m/sec) are unlikely to develop
symptoms due to AS over the ensuing five years.
• A substantial number of patients with severe AS
are not yet symptomatic but these patients have
low event free survival rates (56 to 63 percent at
two years and 25 to 33 percent at four to five
years).
• Studies at three different sites illustrate the range
of predictive factors and rates of progression:

10. The strongest predictor of progression
to symptoms is DOPPLER AORTIC JET
VELOCITY
SEVERITY OF AORTIC VALVE
CALCIFICATION IS ANOTHER IMPORTANT
DETERMINANT OF OUTCOME IN
PATIENTS WITH SEVERE AS

11. MEDICAL UNIVERSITY OF VIENNA

17. MAYO CLINIC

20. Clinical Outcomes in Prospective Studies of Asymptomatic
Aortic Stenosis in Adults

21. Clinical Outcomes in Prospective Studies of Asymptomatic
Aortic Stenosis in Adults

22. Risk factors for progression
• The rate of progression of the stenotic lesion and the time to
onset of symptoms varies significantly among patients.
• Whether patients at high risk for rapid progression can be
successfully identified remains controversial .
• Several prospective series have attempted to identify risk
factors for progression in asymptomatic patients (with
symptomatic patients being treated surgically) .
• Among the factors that may be important are:
• Aortic jet velocity and valve area
• Degree of valve calcification
• Response to exercise testing
• Cause of aortic stenosis
• Hypercholesterolemia
• Renal insufficiency
• Hypercalcemia
• Old age
• Male gender
• Smoking

23. Risk stratification in a patient with
asymptomatic severe AS
Abnormal exercise test
Elevated BNP
Moderate to severe valve calcification
Very high aortic velocity (>5 or 5.5 m/sec)
Rapid increase in aortic velocity
Increased hypertrophic LV remodeling
Myocardial fibrosis
Pulmonary hypertension

24. ACC/AHA guidelines on the management of valvular heart disease concluded that
valve replacement should not be routinely performed for isolated severe
AS in asymptomatic patients

25. Surgical versus medical therapy
• Consideration of surgery in an asymptomatic patient
with severe AS requires an appreciation of the relative
risks of surgical and medical therapy.
• The surgical mortality of aortic valve replacement
varies widely.
• If it is not well under 2 to 3 percent, then the operative
risk clearly exceeds the risk (less than 1 percent) of
sudden death in an asymptomatic patient who does
not undergo surgery.
• Furthermore, valve replacement does not abolish the
risk of sudden death.

28. Surgical versus medical therapy
• Insertion of a prosthetic heart valve is also
associated with appreciable morbidity.
• Among the complications of prosthetic heart valves
are prosthesis dysfunction, paravalvular leak,
thrombus formation, arterial embolism,
endocarditis, and the problems associated with
anticoagulation.
• The incidence of serious complications depends
upon the type of valve and a number of clinical
variables, but significant complications occur at a
frequency of at least 3 percent per year, and death
due directly to the valve occurs at the rate of
approximately 1 percent per year.

29. Surgical versus medical therapy-
CONCLUSIONS
OPERATIVE RISK OF AVR
SUDDEN DEATH RISK NOT TOTALLY ABOLISHED
PROSTHETIC VALVE COMPLICATIONS
• Thus, even if surgical mortality can be
minimized, the combined risk of valve
replacement and the late complications of a
prosthetic valve exceed the possibility of
preventing sudden death in a truly
asymptomatic patient.

30. Very severe AS (ASYMPTOMATIC)

32. Comparison of overall survival (A) and survival free of
cardiac death (B) between the early surgery (OP) and conventional
treatment (CONV) groups.

34. Possible role of exercise testing
• Exercise tolerance testing has been proposed as a possible method of
risk stratification in patients with severe AS who are asymptomatic with
routine activity .
• The ability of exercise testing to identify asymptomatic patients with
severe AS who are likely to develop adverse events was assessed in a
meta-analysis of data from seven studies with a total of 491 patients
(mean age 50 to 66 years).
• An abnormal stress test result was defined as development of
symptoms such as dyspnea, angina, syncope or near syncope during
exercise; a decrease in blood pressure or a <20 mmHg increase in
systolic blood pressure during exercise; <80 percent of normal
exercise tolerance; OR ≥2 mm horizontal or downsloping ST segment
depression during exercise.
• In patients with normal stress test results, no sudden deaths were
observed after one year of follow-up. In patients with abnormal stress
test results, 5 percent had sudden cardiac death.
• Adverse cardiac events were observed in 21 percent with normal stress
test results and in 66 percent of those with abnormal stress test results.
• No complications from stress testing were observed.

35. Possible role of exercise testing
• On the other hand, exercise parameters did not add
predictive value to a multivariate model in an earlier
prospective study of 123 asymptomatic patients with mild
to severe valvular AS in whom yearly echocardiography
and exercise testing were performed for a mean of 2.5
years .
• Based upon the available evidence, we do not
recommend routine exercise testing to estimate prognosis
in asymptomatic patients with AS. However, observations
made during exercise may be of some value in providing
an exercise prescription in patients who might otherwise
excessively limit their activity .
• It may also be helpful when the history is equivocal as to
whether the patient does or does not have symptoms

36. Possible role of exercise testing
• ACC/AHA guidelines concluded that the
evidence was less well established but that
exercise testing may be considered in
asymptomatic patients with AS to elicit
exercise-induced symptoms or an abnormal
blood pressure response .
• Exercise testing should not be performed in
symptomatic patients.

37. Criteria for a positive exercise test in asymptomatic
patients with aortic stenosis
 Development of dyspnea, angina, or presyncope or syncope,
which should lead to stopping of the test
 A rise in systolic pressure during exercise of less than 20
mmHg; the test is stopped if the systolic pressure falls more
than 10 mmHg with exercise
 Inability to reach 80 percent of the predicted normal level of
exercise tolerance
 More than 2 mm horizontal or downsloping ST segment
depression compared to baseline that cannot be attributed
to other causes; the test is stopped if there is more than 5
mm ST segment depression
 The development of complex ventricular arrhythmias, such
as ventricular tachycardia or more than four ventricular
premature beats in succession, which should lead to
stopping of the test

38. Possible role of brain natriuretic
peptide
1.Among patients with severe AS, plasma BNP and
N-terminal pro-BNP concentrations are higher in
symptomatic than asymptomatic patients ,
Gerber IL, Stewart RA, Legget ME, et al. Increased plasma natriuretic peptide levels reflect symptom onset in aortic
stenosis. Circulation 2003; 107:1884.
• Levels come down after aortic valve replacement.
Weber M, Arnold R, Rau M, et al. Relation of N-terminal pro B-type natriuretic peptide to progression of aortic valve disease. Eur Heart J
2005; 26:1023.
• Among asymptomatic patients, higher values are
independently predictive of symptom-free
survival Bergler-Klein J, Klaar U, Heger M, et al. Natriuretic peptides predict symptom-free survival and postoperative outcome in
severe aortic stenosis. Circulation 2004; 109:2302.

39. TODAY’S DISCUSSION
SYMPTOMATIC
AS
ASYMPTOMATIC
AS

40. SYMPTOMATIC PATIENTS
• Once even mild symptoms are present, survival is
poor unless outflow obstruction is relieved.
• Survival curves derived from older retrospective
studies show that the interval from the onset of
symptoms to the time of death is approximately 2
years in patients with heart failure, 3 years in
those with syncope, and 5 years in those with
angina.
• More recent series have confirmed this poor
prognosis, with an average survival of only 1 to 3
years after symptom onset.

41. SYMPTOMATIC PATIENTS
• Among symptomatic patients with severe AS, the
outlook is poorest when the left ventricle has failed
and the cardiac output and transvalvular gradient both
are low.
• The risk of sudden death is high with symptomatic
severe AS, so these patients should be promptly
referred for surgical intervention.
• In patients who do not undergo surgical intervention,
recurrent hospitalizations for angina and
decompensated heart failure are common, associated
with significant consumption of health care resources

43. examples
In the PARTNER trial, 179 patients with AS with
heart failure symptoms were assigned to the
standard therapy arm .
The majority of these patients received balloon
aortic valvuloplasty (64 percent during the first
30 days and 20 percent later). The mortality rate
at one year was 51 percent in this group.

44. GUIDELINES

45. SURGERY VERSUS TRANSCATHETER

46. Surgical risk calculation for valve surgeries
• The 2008 Society of Thoracic Surgeons (STS) risk models for CABG, valve surgery, or both
were developed and validated based on data on 774,881 patients operated on during
2002 to 2006. The STS registry includes data from nearly 90 percent of cardiac surgery
providers in the United States . The models provide estimates of risk of mortality as well as
several nonfatal complications such as stroke, renal failure, and prolonged ventilation. A
calculator is available online ( file://www.sts.org/quality-research-patient-
safety/quality/risk-calculator-and-models/risk-calculator ).
• The first EuroSCORE model was developed based upon data from 1995 to stratify risk of
in-hospital mortality . This model has been replaced by the 2011 EuroSCORE II model,
which was developed based on data from 22,381 patients in 43 countries operated on
during May to July 2010 . Overall mortality was 3.9 percent, which is lower than would
have been predicted by old risk models (additive predicted 5.8 percent and logistic
predicted 7.6 percent). A calculator for the EuroSCORE II is available online
( www.euroscore.org ).
• The Ambler risk model for aortic and/or mitral valve surgery with or without concomitant
CABG was developed from data from the Society of Cardiothoracic Surgeons of Great
Britain and Ireland on 32,839 patients who underwent surgery during 1995 to 2003
(file://www.ucl.ac.uk/statistics/research/riskmodel/index.html ). A calculator is available
online ( www.ucl.ac.uk/stats/research/riskmodel ).
Certain limitations as they don’t include
Porcelain aorta(calcified ascending
aorta)
Severe MAC
Severe PAH
Fraility
Nutritional status
These are independently associated with
high surgical risk

47. ISSUES?
• ROLE OF BAV?
• ROLE OF TAVI?
• MANAGEMENT OF AS WITH LV
DYSFUNCTION?
• AS WITH LOW GRADIENT AND LOW CARDIAC
OUTPUT?
• MEDICAL MANAGEMENT?
• ROLE OF STATINS?

48. ROLE OF BAV(Balloon Aortic
Valvuloplasty)
• BAV for degenerative aortic stenosis was initially
described in 1985.
• Degenerative AS is the most common reason for
intervention and it appears to be associated with a
chronic inflammatory process.
• Unlike rheumatic mitral stenosis, commissural fusion is
not the predominant feature in most older adult
patients with calcific AS, and the primary mechanism
of the balloon action is fracture of the nodular calcium
deposits, which improves leaflet mobility during left
ventricular contraction.

49. • Problems with BAV
RECOIL/RESTENOSIS
HIGH COMPLICATION RATE
TEMPORARY BENEFIT
MODEST SURVIVAL BENEFIT

50. UNFORTUNATELY THE BENEFIT IS NOT
DURABLE
• Restenosis with loss of symptom benefit occurs in
approximately 50% by 6 months and in most patients
by 1 year.
• Early restenosis occurring within hours or days results
from early recoil and may be related to the pathology
of the valve components or inappropriate balloon
diameter (due to size or insufficient inflation).
• When restenosis occurs after several months, the
process may be multifactorial, including the original
degenerative process and an altered healing process
with fibrosis and ossification.

51. Balloon aortic valvuloplasty for transcatheter aortic valve implantation is performed under
rapid ventricular pacing (A), which decreases the effective cardiac output by inducing
ventricular tachycardia (B). The balloon catheter (C) must be sized to the aortic annulus to
avoid severe aortic insufficiency. Doubling of the valve area or a decrease in the
transvalvular gradient by more than 50% (D) is considered a successful result.

52. Complications
Mansfield Scientific
Aortic Valvuloplasty
Registry 1986-1988 (N =
492)
Rouen Series 2002-2005
(N = 141)
Procedural death 2 (4.9%) 3 (2.1%)
Postprocedural death (<7
days)
12 (2.6%) 3 (2.1%)
Cerebral embolic events 11 (2.2%) 2 (1.4%)
Transient ischemic attacks 5 (1.1%) 0 (0%)
Ventricular perforation with
tamponade
11 (2.2%) 0 (0%)
Severe aortic insufficiency 5 (1.1%) 2 (1.4%)
Vascular complications
(surgical repair)
27 (5.5%) 0 (0%)
Nonfatal arrhythmias 5 (1.1%) 5 (3.5%)
Other: myocardial
infarction, sepsis, renal
failure
8 (1.6%) 1 (1%

53. American heart journal 2014
SUCCESSFUL BAV IN 80.8%
INHOSPITAL MAJOR COMP 6.8%, DEATH IN 2.5%
56% MORTALITY AFTER SINGLE BAV AT 1 YEAR
PATIENTS BRIDGED TO SAVR HAD THE BEST OUTCOME

54. Guidelines- NO CLASS 1 OR 11a
INDICATIONS FOR BAV

55. MOST WOULD AGREE
• It may be used for patients who have symptomatic AS in need of
emergent noncardiac surgery. The hemodynamic improvement of BAV is
immediate, and it may decrease the risk of general anesthesia. In these
situations, the BAV should be reserved for patients with severe AS who
have the potential for hemodynamic compromise.
• It may be used to determine the contributing role of AS to dyspnea in
patients with concomitant severe lung disease and to gauge potential
improvement and risks of undergoing SAVR or TAVR.
• It may be used to assess the myocardial contractile reserve in patients
with a low pressure gradient or low ejection fraction in whom associated
cardiomyopathy is questionable. Patients with no demonstrated
contractile reserve can have a perioperative mortality rate as high as
62%.The indication for SAVR or TAVR can be clarified 2 to 3 weeks after
BAV if the left ventricular ejection markedly improves.

56. ROLE OF TAVI
FIRST ACCOMPLISHED IN 2002

57. NOT EVERY HIGH-RISK PATIENT WITH SEVERE,
SYMPTOMATIC AS NEEDS TO BE TREATED WITH
TAVR
Patient Characteristics Associated With Poor Prognosis After TAVI

58. CURRENTLY 2 AORTIC VALVE SYSTEMS
ARE WIDELY AVAILABLE
The SAPIEN valve (Edwards Lifesciences, Irvine, Calif) incorporates a balloon-expandable stainless steel stent frame
within which are sewn bovine pericardial leaflets . synthetic fabric sealing cuff surrounds the inflow of the valve to
prevent paravalvular leaks. This is the valve evaluated in the PARTNER trial,and it is currently approved for clinical use
in the United States.
Its successor, the SAPIEN XT valve, is constructed of a chromium alloy frame and has various minor improvements and
one major advantage in that it is compatible with newer low-profile delivery catheters.
The next-generation SAPIEN 3 valve is compatible with even lower-profile delivery systems and has various
improvements that facilitate accurate positioning and improve paravalvular sealing

59. CURRENTLY 2 AORTIC VALVE SYSTEMS
ARE WIDELY AVAILABLE
The CoreValve
ReValving System
(Medtronic, Inc.,
Minneapolis)
incorporates a self-
expanding nitinol alloy
frame within which are
sewn porcine
pericardial leaflets. A
pericardial sealing cuff
surrounds the inflow of
the valve

60. Study N
Age
(yr)
ES
(%)
STS
Score
(%)
PS
(%)
AVA
Pre-P
(cm2)
AVA
Post-P
(cm2)
Mean
Gradi
ent
Pre-P
(mm
Hg)
Mean
Gradi
ent
Post-P
(mm
Hg)
NYHA
Class
III/IV
Pre-P
(%)
NYHA
Class
III/IV
at 1 Yr
(%)
LVEF
Pre-P
(%)
LVEF
Post-P
(%)
Surviv
al at
1 Yr
(%)
PARTNER
cohort B
2010
358 83.1±8
26.4±1
7.2
11.6±6 96.6
0.6±0.
2
1.5±0.
5
44.5±1
5.7
11±6.9 92
16 54 57 69
PARTNER
cohort A
2010
699 83.6
29.3±1
6
11.8±3
.3
90.2
0.7±0.
2
1.59±0
.4
42.7±1
4
10.2±4 93 12
52.5±1
3
56±10 75.8
SOURCE XT
2015 2166 81.4±6
20.5±1
2
8.4 NR 0.7 1.8 47.6 10.8 76.9 12.3 NR NR NR
FRANCE 2
2015 2107 82.9±7
22.2±1
4
15.6±1
2
96.9 0.7±.2 NR
48.6±1
6
NR 75.5 10.5
53.8±1
4
NR 76
PARTNER 2
2015 284 84±8.7 NR 103±5 96.3
0.6±0.
2
1.6
45.2±1
4
10 96.8 12 52±13 NR 77.5

62. Results of the inoperable arm
• Patients randomized to TAVR had lower rates of all-cause
mortality (30.7% vs. 50.7%, P < .001), cardiovascular
mortality (19.6% vs. 41.9%, P < .001), repeat
hospitalization (22.3% vs. 44.1%, P< .001), and the
composite end point of death or repeat hospitalization
(42.5% vs.71.6%, P < .001).
• During up to 2 years of follow-up, there was no evidence
of degeneration of the valvular prosthesis or restenosis.
• Heart failure symptoms were less severe in patients
treated with TAVR. Patients treated with TAVR had a
higher incidence of major vascular complications (16.2%
vs 1.1%, P < .001), major bleeding (22.3% vs. 11.2%, P <
.001), and major strokes (5.0% vs.1.1%, P = .06). In
patients with severe AS who are not suitable candidates
for SAVR, TAVR should be the standard of care.

63. Results for the high-risk operative cohort
• The all-cause mortality rate at 30 days was
slightly lower with TAVR than SAVR (3.4% vs.
6.5%, P = .07) but was similar at 1 year (24.2%
vs. 26.8%), 2 years (33.9% vs. 35%), and 3 years
(44.2% vs. 44.8%).
• Although the rates of all neurologic events were
higher after TAVR at 30 days and 1 year (5.5% vs.
2.4% and 8.3% vs. 4.3%, P < .05), rates of major
strokes were not significantly different between
TAVR and SAVR at 30 days (3.8% vs. 2.1%, P = .2)
or at 1 year (5.1% vs. 2.4%, P = .07).

64. • There were other important differences in
periprocedural risks between the two groups, with
more major vascular complications 30 days after TAVR
(11.0% vs. 3.2%, P < .001)
• More major bleeding (19.5% vs. 9.3%, P < .001) and
new-onset atrial fibrillation were common(16.0% vs.
8.6%, P = .006) after SAVR.
• Marked improvement of symptoms was similar after
TAVR and SAVR, and it was sustained at 3 years for both
groups.
• From these results, TAVR emerged as a viable
alternative to SAVR for high-risk patients. The choice
is made by the interdisciplinary heart team.
Results for the high-risk operative cohort

65. Study
Proc.
MR (%)
30-Day
MR (%)
Valve in
Valve
(%)
Conv.
Open
AVR
(%)
AI >2+
(%)
Major
CVA or
TIA (%)
Major
VC (%)
MI (%) AKI (%)
PM (%)
(PACE
MAKER
)
Major
Bleedin
g (
PARTNER
Cohort A 0.9 3.4 2 2.6 12.2 5.6 11 0 1.2 3.8 9.3
PARTNER
Cohort B 1.1 5.0 1.7 0 12 5/0 16.2 0 1.1 3.4 16.
PROCEDURAL CHARACTERISTICS AND COMPLICATIONS

66. Durability
• Current transcatheter valves appear to be sufficiently
durable to provide benefit in the mostly elderly patients
with comorbid conditions who are currently considered
candidates.
• Accelerated wear testing has demonstrated in vitro
durability of longer than 10 years, but midterm structural
valve failure has not been rare, although clinical follow-up
remains limited beyond 3 to 5 years.
• Whether such durability is sufficient for younger patients
with the potential for longevity remains to be determined.
• However, the feasibility of transcatheter valve-in-valve
implants in failing surgical and transcatheter
bioprosthetic prostheses has been demonstrated, and this
strategy may be appealing when eventual transcatheter
valve failure occurs

67. CONCLUSION
• Surgical aortic valve replacement remains the
current standard of care for symptomatic aortic
stenosis because of a large body of favorable
experience .
• In the absence of long experience and
additional randomized comparisons, current
guidelines recommend TAVR only for patients
in whom the risk for morbidity or mortality
with surgery is high (STS SCORE>10%)

68. MANAGEMENT OF AS WITH LV
DYSFUNCTION
• SURGICAL RISK IS HIGHER
• OVERALL PROGNOSIS EXTREMELY POOR WITHOUT
AVR
• AVR LEADS TO SIGNIFICANT CLINICAL AND
FUNCTIONAL RECOVERY.
• AVR IS THE PREFERRED MODALITY OF TREATMENT
• TAVI SEEMED BENEFICIAL IN SOME NONRANDOMIZED
STUDIES
• RCTs ARE REQUIRED TO MAKE A CONCLUSION.

69. GUIDELINES

70. AORTIC STENOSIS WITH LOW GRADIENT
AND LOW CARDIAC OUTPUT
• Patients with critical AS, severe LV dysfunction,
and low cardiac output (and hence a low
transvalvular pressure gradient) often create
diagnostic dilemmas for the clinician because
their clinical presentation and hemodynamic data
may be indistinguishable from those of patients
with a dilated cardiomyopathy and a calcified
valve that is not stenotic.
• Low-flow, low-gradient AS is defined as a valve
area of 1.0 cm2 or smaller, with an aortic velocity
of less than 4.0 m/ sec or mean gradient of 40
mm Hg or less

71. • Most often, low-gradient low-flow AS occurs in
patients with a low ejection fraction (<50%). In this
situation, severe AS can be distinguished from
moderate AS with primary LV dysfunction based on the
changes in valve hemodynamics during transient
increases in flow, usually by increasing cardiac output
with dobutamine.
• Severe AS is present if there is an increase in aortic
velocity to at least 4 m/sec at any flow rate, with a
valve area that remains less than 1.0 cm2; AS is not
severe if the valve area is more than 1.0 cm2

72. • Dobutamine echocardiography also provides
evidence of myocardial contractile reserve (an
increase in stroke volume or ejection fraction
>20% from baseline), which is an important
predictor of operative risk, improvement in LV
function, and survival after AVR in these patients.
• However, even in patients with a lack of
contractile reserve, AVR should be considered if
the mean gradient is greater than 20 mm Hg,
because survival after AVR is better (roughly 50%
at 5 years) than with medical therapy.

73. A, Increase in cardiac output and in mean aortic valve gradient from 24 to 47 mm Hg. Aortic valve area (AVA) remained 0.8 cm2. This
patient underwent successful valve replacement.
B, Increase in cardiac output and minimal increase in mean pressure gradient from 17 to 20 mm Hg. The final calculated aortic valve area
was 0.7 cm2. The patient was found to have only minimal AS at the time of surgery.
C, No change in cardiac output, with decrease in mean pressure gradient from 37 to 26 mm Hg, occurred in response to dobutamine. The
test was terminated because of hypotension. The patient was found to have severe AS at the time of surgery

74. Medical management of AS
• Most important principle in management is patient
education regarding the disease course and typical
symptoms.
• Patients with severe AS should be cautioned to avoid
vigorous athletic sports and physical activity. Such
restrictions do not apply to patients with mild obstruction.
• Although medical therapy has not been shown to affect
disease progression, adults with AS (as with any other adult)
should be evaluated and treated for conventional coronary
disease risk factors, in accordance with established
guidelines.

75. Medical management
Symptomatic aortic stenosis (AS) is an indication for aortic valve replacement and
medical therapy has limited utility in treating symptoms. However, medical
management may be required in patients who are not candidates for surgery (either
due to comorbid conditions or patient refusal to undergo valve replacement).

76. Frequency of echo in asymptomatic
patients with normal LV function
Severity ECHO
MILD 3-5 yearly
MODERATE 1-2 yearly
SEVERE 0.5-1 yearly

77. • Although diuretics are beneficial when there is abnormal
accumulation of fluid, they must be used with caution because
hypovolemia may reduce the elevated LV end-diastolic pressure,
lower cardiac output, and produce orthostatic hypotension.
• ACE inhibitors should be used with caution but are beneficial in
treating patients with symptomatic LV systolic dysfunction who are
not candidates for surgery and, in fact, have been shown in
epidemiologic studies to improve outcomes in patients with AS
• They should be initiated at low doses and increased slowly to target
doses, avoiding hypotension.
• Beta-adrenergic blocking agents can depress myocardial function
and induce LV failure and generally should be avoided in patients
with AS.

78. ATRIAL FIB
• AF or atrial flutter occurs in less than 10% of patients with severe
AS, perhaps because of the late occurrence of left atrial
enlargement in this condition.
• When such an arrhythmia is observed in a patient with AS, the
possibility of associated mitral valvular disease should be
considered.
• When AF occurs, the rapid ventricular rate may cause angina
pectoris.
• The loss of the atrial contribution to ventricular filling and a sudden
fall in cardiac output may cause serious hypotension.
• Therefore AF should be treated promptly, usually with
cardioversion.
• New-onset AF in a previously asymptomatic patient with severe AS
may be a marker of impending symptom onset

79. NONCARDIAC SURGERY AND
PREGNANCY
• Adults with asymptomatic severe AS can
undergo noncardiac surgery and pregnancy,
with careful hemodynamic monitoring and
optimization of loading conditions.
• When stenosis is very severe, however,
elective AVR before noncardiac surgery or a
planned pregnancy may be considered.

80. ROLE OF STATINS?
• Although elevated serum lipids are associated
with the presence of aortic valve disease, to
date there is no convincing evidence that lipid-
lowering therapy affects disease progression.
• No benefit was seen in a small prospective
randomized trial of atorvastatin versus
placebo, despite a significant lowering of
serum LDL levels, in patients with relatively
advanced calcific AS

81. The Simvastatin and Ezetimibe for Aortic Stenosis (SEAS)
Trial and the Aortic Stenosis Progression Observation:
Measuring Effects of Rosuvastatin (ASTRONOMER) Trial
randomly assigned 1800 and 269 adults, respectively, with
mild to moderate AS to intensive lipid-lowering therapy
versus placebo.
These studies were adequately powered and showed no
improvement in mortality, time to valve replacement, or
rate of AS progression in the treatment versus placebo
groups.

82. TAKE-HOME MESSAGES
• Hemodynamic progression of AS is variable. The aortic valve
area declines at an average rate of 0.1 cm 2 per year but
some patients have little or no progression and others
progress more rapidly.
• Peak aortic velocity and/or rate of progression of peak aortic
velocity is associated with risk of death or aortic valve
replacement.
• Mortality in patients with AS dramatically increases after the
development of the cardiac symptoms.
• Symptomatic aortic stenosis (AS) is an indication for aortic
valve replacement and medical therapy has limited utility in
treating symptoms.
• TAVI is a suitable alternative in elderly patients with high
surgical risk

83. THANKYOU

84. RESULTS POST AVR
• Symptoms of pulmonary congestion (exertional dyspnea) and of myocardial
ischemia (angina pectoris) are relieved in almost all patients, and most patients
will exhibit an improvement in exercise tolerance, even if it was only mildly
reduced before surgery.
• Hemodynamic results of AVR also are impressive; elevated end-diastolic and
end-systolic volumes show significant reduction.
• Impaired ventricular performance returns to normal more frequently in
patients with AS than in those with AR or MR.
• However, the finding that the strongest predictor of postoperative LV
dysfunction is preoperative dysfunction suggests that patients should, if
possible, be operated on before LV function becomes seriously impaired.
• The increased LV mass is reduced toward (but not to) normal within 18 months
after AVR in patients with AS, with further reduction over the next several
years.
• Coronary flow reserve and diastolic function also demonstrate considerable
improvement after AVR. However, interstitial fibrosis regresses more slowly
than myocyte hypertrophy, so that diastolic dysfunction may persist for years
after successful valve replacement.

87. RESULTS POST AVR