Dr. Catherine M. Otto
This session addressed some of the current clinical challenges we face in caring for adults with calcific aortic valve disease. Raphael Rosenhek discussed the management of asymptomatic patients with severe aortic stenosis (AS). When severe AS is present, the first step is to ensure the patient is truly asymptomatic by a careful clinical history, consideration of exercise testing if symptom status is unclear and measurement of serum BNP levels. Even if truly asymptomatic, predictors of progression to symptom onset include a higher aortic velocity, more calcified valve, more rapid hemodynamic progression (over 0.3 m/s/year) and older age. The 2012 ESC Guidelines for Valvular Heart Disease recommend aortic valve replacement (AVR) in asymptomatic adults with severe AS when left ventricular (LV) systolic dysfunction is present or when symptoms are provoked on exercise testing. AVR also may be considered when there is severe valve calcification, rapid hemodynamic progression or very severe AS with an aortic velocity over 5.5 m/s. However, a careful assessment of the risk-benefit ratio of AVR is especially important in the asymptomatic patient. Javier Bermejo then addressed the problem of aortic stenosis with hypertension or the “double loaded” ventricle. His take home messages were that hypertension may affect evaluation of AS severity and that control of blood pressure is important in adults with AS. Treatment should be monitored closely but blood pressure control with angiotensin converting enzyme inhibitors or receptor blockers is associated with improved clinical outcomes. Philippe Unger then discussed management of the patient with AS and concomitant mitral regurgitation (MR). In this situation, the mechanism of mitral regurgitation must be determined because functional MR is more likely to improve after relief of AS than organic MR, which likely will require an additional mitral valve procedure. Further clinical studies on this challenging clinical problem are needed. The session concluded with a presentation by Philippe Pibarot on low-flow low-gradient aortic stenosis. In a subset of AS patients, transaortic volume flow rate is reduced, either due to LV systolic dysfunction with a low ejection fraction or due to a small ventricular chamber with a preserved ejection fraction. Quantification of AS severity is challenging in this situation because the aortic velocity and pressure gradient are lower than expected for the decrease in valve area. In symptomatic patients, it is important to identify those with severe AS and low-gradient because these patients benefit from AVR. The typical patient with low-output low-gradient severe AS with normal ejection fraction is an elderly woman with severe LV hypertrophy and a calcified aortic valve.
Challenges in the evaluation and management of aortic stenosis
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