Aortic Stenosis

A new treatment without open heart surgery

Aortic stenosis is one of the most common heart valve problems. Due to a genetic susceptibility, the aortic valve gradually gets stiff and rigid, so that the heart muscle has to make extra effort to push the blood across the diseased valve. That increases strain on the heart and in advanced stages can cause insufficient oxygen supply to the body. The aortic stenosis can remain asymptomatic for a long time but once it reaches a severe stage as assessed on echo, the symptoms usually follow within months. The usual initial symptoms include reduced exercise tolerance, tiredness and shortness of breath on exertion. Later, patients experience chest discomfort (which can be sometimes due to concomittant coronary artery disease) and finally dizziness and blackouts. When the symptoms appear, the disease is normally well advanced and necessitates a prompt treatment. Sometimes, an incidental finding of a murmur on a routine medical check leads to echo which confirms severe aortic stenosis. The plan then is usually 6-monthly clinic and echo follow-up and as soon as symptoms appear, patient is listed for coronary angiogram with a view for referral for aortic valve replacement. The prognosis is symptomatic severe aortic stenosis is bleak. If there are doubts about presence of symptoms, exercise tolerance test can be helpful in distinguishing between truly asymptomatic patients (with a plan for watchful waiting) and patients who have symptoms but got used to them and don't really perceive any undue limitations (but still need an operation). 

There are two types of aortic stenosis: congenital and acquired. Congenital aortic stenosis is diagnosed in young people and is relatively rare. The vast majority of cases is acquired aortic stenosis of degenerative origin due to a process of wear and tear. The incidence of aortic stenosis increases with age. It is estimated that 29% of people older than 65 years and 37% people above 75 years have some stage of aortic stenosis. The disease is more common in men than in women.

Treatment options nowadays include an established and time proven aortic valve replacement (AVR) and newer and less invasive transcatheter aortic valve implantation (TAVI). AVR is a first option in majority of patients. AVR is an open heart surgery performed under general anesthesia. During the operation, the heart is stopped, and the device for artificial circulation is connected. The heart is then opened, and the old stenotic valve is replaced with a new metallic or tissue valve. It is obviously a major procedure but the operation has great success rate and the risk of complications is relatively low. TAVI does not require opening of the chest, because the artificial valve is usually delivered to the heart via a large catheter through an artery in the leg. This technique is less invasive but it is still a substantial procedure which in many patients requires preventative implantation of a pacemaker. TAVI can be used in some patients in whom open heart surgery is contraindicated.

Dr Ruzicka has substantial experience in diagnosis of aortic stenosis and can recommend optimal follow-up and treatment options.

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