engleski

Management of aortic stenosis

Aortic stenosis (AS) is the most common valvular heart disease today. Atherosclerotic AS occurs in elderly population, it is less common in younger persons as a congenital anomaly, while rheumatic AS is rare. It is extremely important to detect the presence of symptoms: exertion intolerance and shortness of breath during activity, angina, dizziness or syncope. The symptoms are not always manifest, since the elderly population are usually less physically active. The length of the characteristic murmur, weakening of the second heart sound over the aortic valve and a change in the quality of the carotid pulse all indicate a hemodynamically significant AS, while the intensity of the murmur is a less reliable sign. Echocardiographic examination confirms the diagnosis, evaluates the severity of AS, analyzes the left ventricle (LV) and other heart structures. In the evaluation of severity it is important to determine transvalvular peak flow velocity, pressure gradient, valvular area and LV condition. Valvular area of <1.0 cm2 in persons of average built, and valvular area of <0.6 cm2/m2 of body surface in persons with small and large body surface, is a sign of severe AS. At normal LV function and normal transvalvular flow, medium pressure gradient of <50 mmHg excludes severe AS, but at reduced flow due to LV systolic dysfunction, pressure gradient and valvular area are not necessarily reliable indicators. In such cases, dobutamine stress echocardiography test helps to determine whether it is really a severe AS. All symptomatic patients with severe AS require early aortic valve replacement. The decision on the optimum time for surgery in asymptomatic patients with severe AS demands careful consideration and risk/benefit evaluation. Early elective surgery is recommended for the following asymptomatic patients: 1) with LV systolic dysfunction (EF <50%) not due to another cause, 2) with positive exercise test and 3) with echocardiography predictors of poor prognosis (calcified valve with rapid increase in peak flow velocity of >0.3 m/s annually). Balloon valvuloplasty is used only as a bridge towards surgery in hemodynamically unstable high risk patients and in patients with symptomatic severe AS who need urgent major non-cardiac surgery. Appropriate medication should be carried out in all patients.

aortic valve stenosis; diagnosis; treatment

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