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Severe aortic stenosis: which patient? Which valve?

  • Asymptomatic very severe aortic stenosis (high peak aortic-jet velocity). Presented R Rosenhek (Vienna, AT),
  • Low-gradient aortic stenosis with preserved left ventricular ejection fraction: asymptomatic patient. Presented by N Jander (Freiburg, DE),
  • Low gradient aortic stenosis with preserved left ventricular ejection fraction: symptomatic patient. Presented by P Lancellotti (Liege, BE)
Valvular Heart Diseases

This Focus session started with a case presentation by Raphael Rosenhek on an elderly asymptomatic patient with very severe aortic stenosis (AS). 

A step-by-step approach to this clinical problem was summarized by Catherine Otto as follows:

  1. Look at the valve - ensure the accuracy of AS measures and evaluate valve anatomy (number of leaflets, degree of calcification, mobility).
  2. Listen to the patient – ensure the patient is truly asymptomatic and consider exercise testing if symptom status is unclear.
  3. Evaluate the left ventricular response to chronic pressure overload—ejection fraction, hypertrophy, diastolic function, and pulmonary pressures.
  4. Estimate the risk of disease progression – risk stratification may include measurement of serum natriuretic peptide levels, assessment of the rate of disease progression and leaflet calcification.
  5. Assess the risk-benefit ratio of aortic valve replacement - comorbidities are common in elderly AS patients and are important in decisions about the timing and choice of intervention.

Next, Nikolaus Jander presented a case of low-gradient AS with preserved LV ejection fraction in an asymptomatic patient, showing that this patient had only moderate AS and did well with watchful waiting over a long follow-up interval. In contrast, Patrizio Lancellotti presented a case of symptomatic low-gradient AS with preserved ejection fraction, showing that this patient did, in fact, have severe AS and benefited from transcatheter aortic valve replacement. The panel discussed approaches to diagnosis of severe AS in patient with low-output AS emphasizing the importance of clinical symptoms, the need to evaluate other potential causes of symptoms (such as coronary or pulmonary disease) and the role of imaging and stress testing in this challenging clinical situation.




Severe aortic stenosis: which patient? Which valve?

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.