Most common etiologies of AS

• Calcification of a normal aortic valve overtime with age
• Bicuspid aortic valve
• Rheumatic heart disease (usually associated with mitral valve disease)

Symptoms

• Dyspnea (most common)
• Angina
• Syncope

Diagnosis

• Physical exam
  • Systolic ejection murmur at RUSB with radiation to the carotids
  • Any maneuver that decreases blood flow across the valve will cause a decrease in the sound of murmur (e.g. valsalva, handrip, or standing) whereas anything that increases blood flow across the valve will increase the sound of the murmur (e.g. squatting)
• Transthoracic echo
  • Severe AS is AVA < 1 cm2, mean gradient greater or equal to 40, or max velocity greater than 4 m/s

Low-flow, low-gradient AS

• If patient has an AVA < 1 cm2 but has a mean gradient < 35 mmHg, consider low-flow, low-gradient AS
• To determine whether there is an intrinsic problem with the valve versus a pseduo-aortic stenosis due to myocardial dysfunction, do a dobutamine stress echo
• If AVA remains unchanged and the mean gradient increases with dobutamine, the etiology is severe AS and the patient would benefit from valve replacement
• If the AVA increases and the mean gradient doesn’t increase, this is a pseudo-aortic stenosis and the patient can be managed medically

When to treat?

• Any patient who is symptomatic
• An asymptomatic patient with EF < 50 or who is getting another cardiac surgery

Treatment

• AVR > TAVR if the patient is a surgical candidate
• TAVR is good for high risk patients and has similar survival to AVR in high-risk patients
• AV balloon valvuloplasty is a short-term bridge to TAVR as it only lasts a few months
• Medical management is usually not beneficial if a patient has severe AS