Chapters Transcript Video Aortic Stenosis Today I'm presenting on aortic stenosis, um, just an introductory lecture that Doctor Cohen will continue, uh, talking about post, uh, implant, you know, post intervention, um, next slide, sorry. So, um, I have no relevant disclosures. And, uh, learning objectives for today, uh, we'll review prevalence and natural progression of aortic stenosis will recognize aortic stenosis, um, we'll understand and discuss echo findings, and, um, we'll also discuss when to refer, um, and how to screen the patients, uh, with different degrees of aortic stenosis. We'll review, um, ACCHA guidelines and timing of aortic valve replacement and briefly touch on Sava versustaver. I know it sounds very loaded, uh, it's a lot of information, uh, you know, all of these, um, you know, topics require probably like hours of lectures, but I'll try to summarize the most important concepts. So, um, um, the basically aortic stenosis represents one of the most prevalent, um, valliary diseases in adults and as we know and, you know, um, around the world and, um, contributes to significant morbidity and mortality. Um, aortic stenosis is defined as valve leaflet disease leading to left ventricular outflow obstruction, uh, caused by a progressive lethal calcification, fibrosis. It affects around 12.5 million people globally, and, uh, aortic stenosis is the most, um, frequent. Valvular heart disease in Western countries affecting about 5%. That's a lot of people, individuals aged of about um 65 years of age. For individuals about 80 years of age, the prevalence is 10%. Uh, so it is the disease of the elderly as we know. Um, the pathogenesis of aortic stenosis, um, basically there's mechanical stress, um, on the aortic valve, and that leads to, as you know, endothelial dysfunction, um, anytime there's endothelial dysfunctions, you know, something that's very similar for. Um, you know, coronary artery disease, uh, there's activation of immune response system, macrophages, lymphocytes that in itself, um, you know, there's then accumulation of LDL, um, and lipid, um, you know, uh, lipids in the area which then leads to further and, you know, cytokine release and inflammatory response, uh, which then leads to fibrosis and calcifications, fibroblasts in that area that what's basically calcifies the valve and leads to aortic stenosis. Um, causes of aortic stenosis, um, uh, you know, um, about 50%, uh, of patients are, uh, congenitally acquired disease, uh, by gaspar aortic valves, uh, because of their altered hemodynamics, uh, that leads to, you know, earlier activation of the immune, uh, response systems and, you know, uh, fibrosis and gas. Specifications patients in that category tend to be um younger 40 to 50 years of age um uh so that's about 50% of cases. Another 50% that you'll see will be your uh typical uh disease of the elderly aortic stenosis, uh, normal from normal tricuspid aortic valve. About 5% less than 5% of patients. Have rheumatic heart disease. Uh, most commonly affected valve is mitral valve, uh, but about 30% of patients have, uh, also aortic valve affected as well. Um, and all, all the way to the left you have normal leaflets, uh, thin, um, you know, without any calcifications. That's the ideal look of the aortic valve over there. Um, this is a very kind of important, um, uh, topic, you know, here to discuss and understand that, and this, you know, this concept was introduced by Eugene Brownwald and John Ross many, many years ago, like in 1968, and, uh, so as we know there's latent period, um, if you see that red line. So there's latent period where patients have initially fibrocalcific changes of the valve, then they develop mild aortic stenosis or moderate, and that lasts for years, right? It depends on uh how much we control the comorbidities, but basically, uh, lasts for years and then um. Uh, and then you have basically the next line when you have onset of severe symptoms. Um, there's some other symptoms that I'll talk to you about that appear first, but once you have the onset of severe symptoms, um. And um that leads to basically uh if left untreated at that time that leads to 50% mortality within 2 to 5 years so we kinda don't want to uh have see the patients hopefully much earlier uh symptoms of the severe aortic stenosis uh are caused by inadequate um increased in cardiac increase in. Cardiac output with exercise or or with daily activity leading to ischemia um it leads to chest pain uh it leads to decrease in blood pressure which can lead to dizziness, lightheadedness, syncope, um, another late manifestation you have high feeling pressures uh which lead to pulmonary congestion and um. Uh, fluid overload and edema. So again, ideally the first most common symptom that the patients with the aortic stenosis will develop is increase in, um, decrease in baseline exercise capacity. So if you see them, uh, many, many times I see patients in my clinic. They, you know, they usually say we're all have no symptoms, but if you really dig in and you start talking to the patient, just, just, just the other day I saw a patient with, you know, severeortic stenosis who everyone's label, you know, said asymptomatic, but he actually stopped moving progressive. Over the years and you know, uh, patient just slowed down and all, all he does is just moves from a chair to TV to bed, you know, doesn't really do anything so you know that's kind of your sign to go and dig deeper and understand, you know, really, uh, get your symptoms out of the patient. Um, and so that would be the first thing, decrease in baseline extra capacity and obvious dyspnea and exertion that's, you know, um, progressively worsened over the years as well. So, um, again we want to see the patients discover hopefully, um, aortic stenosis earlier and monitor them and not. Not have not see them at syncopal heart failure angina level um but of course we'll see them at that time as well. Important to educate the patients on, um, you know, especially those asymptomatic AS patients on the symptoms and importance of, um, timely intervention as well. So the typical, uh, the patho, you know, the typical causes of aortic stenosis are the same causes for many, many other things in the cardiovascular, um, specialties. So, um, anything that really causes coronary artery disease also causes aortic stenosis, obesity, hyperlipidemia, uh, smoking, renal dysfunction. Uh, basically your cardio metabolic syndrome, diabetes, uh, uh, uncontrolled hypertension for years, you know, that's, that's really easy to kinda understand because it's a sheer stress applied to the aortic valve, uh, and, um, uh, so very, very similar, uh, um, kinda causes as for coronary artery disease as well. So, uh, I'm glad Doctor, he gave us a lecture about heart failure because, uh, stages of aortic stenosis are very similar to heart failure stages, um, you know, they're, you, you know, same, uh, pretty much stages. So stage A is your, uh, just like in heart failure is your patient, uh, at risk for aortic stenosis and then. A lot of this you'll see in the community when we describe on our echo patient has fibrocalcific changes of the aortic valve, uh, but their peak velocity through that valve is less than 2, which is, you know, um, basically not really aortic stenosis yet, but there, you know, you notice that the valve has already changes, so that, that's the patient at risk. Um, and we'll talk about, uh, there's no really medical therapy that can, uh, decrease the progression of, uh, you know, um, or of, uh, uh, aortic stenosis, but there's some things we can do to, uh, you know, uh, to basically slow down, um, um, some of them, uh, I, I'll discuss a bit later. So, um, stage B is your progressive aortic stenosis. It's could be mild or moderate. Uh, mild is, um. When you have your peak velocity at 2 to 2.9 m per second and mid gradient less than 20 m per second and um your moderate aortic stenosis is your peak velocity 3 to 3.9 m per second and mean gradient of 20 to 39 millimeters per mercury uh and stage C um is divided in 21, it's severe asymp basically it's asymptomatic stage when the patient's telling you. Have no symptoms, um, but we, they, they do have severe AS whether with normal ejection fraction or ejection fraction less than 50 and, uh, you know what are the echo parameters, uh, that we're looking at, um, to diagnose aortic stenosis on echo is peak velocity over 4 m per second, mean gradient over 40 millimeters per mercury, aortic valve area less than 1 centimeter squared. Um, and that's basically the three important parameters where you're looking to diagnose, and again, stage C is asymptomatic still but severe. And, uh, stage D, um, it's the, you know, uh, three categories, but these are all symptomatic patients. um, there's stage D1 is your classic severe, uh, symptomatic aortic stenosis. Stage D2 is the, um, this entity called low flow, low gradient aortic stenosis is, uh, basically in patients with cardiomyopathy, um, their aortic, you know, they have severe range aortic valve, uh, uh, with, um. Aortic valve area less than one, but their mean gradient and their uh peak pressure are sort of not able to, you know, are not going up in that severe range but the aortic valve area is um you know reduced so then this is the entity we kinda I will talk about how do you really. Determine whether this is a myocardial disease and the patient just can't open that valve uh because of the reduced ejection fraction or is this truly severe aortic stenosis so this is one of those entities that we'll talk about uh a bit later just to see how, how we go, what's the approach there. And the third D3 stage is uh severetic stenosis with normal ejection fraction, but when their stroke volume is lower, usually happens in smaller hearts, um, you know, uh, smaller patients, smaller cavities, basically, um, and, uh, I'll touch briefly on that as well a bit later. So stage A, B, C, D, just like the heart failure. On physical exam, um, uh, this is, you know, a lot of you guys, you know, are great at this because I've got a lot of referrals for aortic stenosis when the murmur was picked up, um, amazing, good job, uh, but basically we usually hear the murmur at the grade about 33 out of 6, and the systolic murmur at the cardiac base, and, um, about 20% of patients would have a softer murmur. Um, there's also diminished and delayed carotid upstroke, um, it, which is a actually very specific finding, uh, for severe aortic stenosis. So if, if you end up hearing that, that's great, uh, the, you know, uh, order the echo and send them right to us right away. You don't even have to wait for the, um, echo, uh, to come back, um. Uh, so late peeing systolic murmur you can hear a single quiet as to, um, and you know if you don't hear the murmur, um, but you're still suspecting from the history that you're suspecting a valvular disease or maybe you're not sure what you heard, still order an echo, um, you know, don't hesitate, uh, because sensitivity, uh, of a murmur for diagnosis of any valvary disease is less than 50%. Specificity is about 70%, and echo is a definitive test to diagnose aortic stenosis. Um, echo parameters again, uh, kind of mentioned it a little bit, but the most important, uh, things to look at, and this is, um, by the way, an image of, uh, 5 chamber view when we put, uh, uh, continuous wave Doppler through the aortic valve, um, to get the peak velocity mean gradient, and then using Bernoulli equation we calculate aortic valve area. So again, VMAX here as you see, and you know if uh I. Recommend looking at these echoes sometimes it's, you know, very interesting. You can get a lot of information, but this is where you get a lot of information just on the slide. You see the VM max over there, that's your peak velocity, 4.2 basically. So that's crossed over in the severe. You have the mean gradient, uh, over there 45, so that's severe, uh, and your aortic valve area here is, uh, less than 1, it's 0.7 centimeters squared. So, um, you also have to assess the OV function as well. Um, as other things in echo, but this is, um, kind of what how we look important things to consider, um, you know, and this is a bit, uh, technical, but, you know, if let's say you, you got your echo and it's not coming out to be severe, um, some things to consider is that, you know, if we ever mention like a technically difficult study, uh, you know, we're gonna always worry about the potentially underestimating the severity of aortic stenosis. Let's say your your patients endorse. Symptoms that kind of sounds like severe AS, but for some reason on echo, you know, it's not, it was a dread like moderate, you know, still send them to us because these are some of the things we'll be checking to make sure that the echo everything was measured appropriately, uh, that the isolation beam was aligned with the valve appropriately so this, you know, if you have a high suspicion, do not hesitate to refer them to us as well because we'll be checking for, you know, for errors on the echo as well. Uh, and again this is the Bernoulli equation, um, we use pretty much for every valvular disease, uh, including aortic stenosis, uh, in echocardiography. You basically have two sites, uh, and you're still, you know, you have the data from, uh, left ventricular outflow track and you're solving for the area of the aortic valve, basically you just, uh, uh, I mean that's kind of how you calculate it, um, on the echo. And uh uh this is, you know, we went over the stages of aortic stenosis, but this is just for, uh, emphasis of echo surveillance. Uh, a lot of you guys will be seeing the patients in the community with mild moderate aortic stenosis. So for mild aortic stenosis, the recommendation is 3 to 5 years echo surveillance for moderate is 1 to 2 years to obtain the echo, and, uh, I would say it's moderate. Or if there's any ever mention of low flow, low gradient somewhere, I recommend just sending them to us, uh, right away, um, starting moderate and low flow, uh, comments if there's ever, um, an obvious severe, of course, I'm happy to see them. But with severe we'll be screening them. um, we're either gonna be doing an intervention on them or we'll be, we'll be screening some patients every 6 months to 1 year. So, um, one more time, um, you know, uh, about low flow, low gradient, uh, aortic stenosis, um, severe aortic stenosis, so, um, this is like that time when you have a discrepancy, your aortic valve, uh, uh, valve area comes out to be less than one. Uh, your ejection fraction in this case is less than 50, but your gradient and your, uh, peak velocity is not there, right? So what do you do with those patients? So we can do the buttamine stress echo in those patients to see. Basically what we're looking at is to answer the question, is it a pseudo severe, uh, aortic stenosis, uh, is the problem, uh, is the problem myocardium in this case? So we're trying with the buttamine we're trying to augment patients' contractility, uh, by about 20%, uh, you know, ideally to, um, and see if the aortic valve area. Still stays less than one and if the gradients go up basically uh to hopefully severe range so if that happens then you know if your valve is still low and your gradients go up, that means that it's truly severe aortic stenosis. Uh, what happens in those pseudo severe cases, it's probably just a uh uh a disease of a myocardium. And um you know that an aortic valve area in those patients will go you know increase to above 1 and and those patients the peak velocity uh will not mean gradient will not change if you're in in in the case of let's say you're doing the minimum stress echo but your contractility has not augmented by 20% that happens. There's other things we can do. We can do a TEE. Uh, to take a look and measure the, the aortic valve directly, or we can do a calcium score. Actually we do, we do a lot of time was to do a combination of many of these tests together to really arrive at the answer because then they have to see heart failure as well, uh, to help with, um, you know, uh, possible, um, you know, advanced therapies and things like that. So it's, you know, this, these are the kind of patients that are usually pretty sick, um, and, uh, a lot of, you know, a lot of RT will be involved here. So again, calcium score. You, if you obtain your calcium score, we do a CT scan for that, and you see that's, uh, one of the CT scans we basically just literally directly measure calcium score on the valve just like the coronary arteries we just measure that and if that number comes out to be in men more than 2000 and in women more than 1.2,000. Um, of calcium score in the valve that's indicative of severe. If it's less than yours still could be, uh, you know, um, pseudo severe, and then, um, uh, uh, uh, we can do other tests to check as well. Um, stress, you know, stress testing, uh, in severe AC only asymptomatic aortic stenosis, there is a guideline recommendation for that. If your patient, like I had patients who ran, uh, nearly marathons with severe AS who've worked full time and they have severe AS on echo. So, um, these are the patients that are a bit tough, but let's say you have that patient who you're not sure. They've progressively kinda they don't really go anywhere uh much they don't leave the house, uh, and you so you're not sure if you know what if you put them on a treadmill and see how they do so there's a guideline to a recommendation, um, you know, to do a stress test, uh, but again refer them to us, let us, you know, let us figure out if that would be an appropriate, uh, thing to do. Uh, as well, um, medical therapy, uh, for, you know, in aortic stenosis you gotta treat the hypertension because that's again one of the causes for aortic stenosis. You have to optimize them to your, you know, uh, to, you know, uh, uh, to their, to ideal, uh, high, um, blood pressure, and, um, you have to, you, you treat calcific stenosis with statins. So if you have a calcific stenosis, you start a patient on statin that's for primary and secondary prevention at this point. Um, so timing, uh, in, uh, indications and timing, uh, for AVR, uh, goes like this. So all your class one recommendations would be any time you, you have symptoms from severe aortic stenosis. So you have symptoms, severe aortic stenosis with preserved EF or, you know, reduced EF, that's your, um, basically in class one indication for, um, AVR Tava versus Tava. We'll talk a little bit about that. And um let's say you have no symptoms and you have severe aortic stenosis so you're like in that stage C aortic stenosis um and you have reduced ejection fraction so it's class one recommendation for um for uh a uh aortic valve replacement if you're going for other surgeries and you're asymptomatic, um, but you have going for by. Pass you have to take care of the valve as well, so that's your class one indication as well. Class 2A indication in asymptomatic patients, let's say you put them on a treadmill for a stress test and their blood pressure drops or um they have a decreased exercise tolerance, so that's your class 2A indication for AVR. Um, also, if you're asymptomatic and you have very severe AS, like your peak gradient is 5, very severe, your, your, uh, NTR BNP is, uh, 3 times normal, or your, you have rapid progression of, uh, your, you know, aortic valve disease, let's say your valve, uh, area decreased by 0.3 in a year or so. So, uh, so that's kind of, um, and then you're also low risk surgical patients, so that's an indication for Savr to a recommendation, um. And um what's what are some of the evidence that we have? What about you know which I just mentioned um you know some of the some of things are to a recommendations so what you know uh uh in a very interesting uh uh randomized control trial was published in New Journal of Medicine in 2025 Early Tower. They took purely asymptom. Traumatic, uh, severe aortic stenosis patients, uh, and about 900 patients, and I think 901, I believe this was, uh, yeah, the number of patients, and they ran randomized them into a T versus, uh, routine clinical surveillance, and their primary endpoint was, um, death, stroke, unplanned hospitalization, or cardiovascular cause, um. Uh, so it showed basically that, uh, tower patients that, uh, uh, tower patients, uh, did sta statistically significantly better compared to those, uh, who were uh in the surveillance arm and, uh, if you see here the end points, you know, the primary endpoints occurred in. Only 26.8% of patients with Tver arm, but 45.3% in clinical surveillance arm, uh, and there was no difference in all cause mortality, and I was really also driven by this unplanned hospitalization, uh, for for, uh, for cardiovascular cause a huge separation between those two. So, um, so these again a severe asymptomatic, uh, aortic stenosis patients, um. And multiple, multiple trials. I can't unfortunately go over all of them. They were all, you know, starting with the seminal, you know, papers, uh, partner one, A and one B trials, as we know our colleagues, uh, Doctor Talavia, uh, have been in all of a lot of these, you know, trials forever, but many, many of them since like 2007, I think part of trials came out, uh, basically. Uh, showed that, um, you know, and we'll, we'll talk what they showed basically it showed, um, that, um, in, in, uh, there's no difference in mortality, uh, for tor versus tower patients, and, you know, the only difference in the, you know, uh, the only difference that they found were just kind of specific difference for surgical versus tower patients, so tower had less major. Bleeding shorter, um, hospital stay, more rapid return to activities, less pain, reduced onset of Afib than inav and summerav valves had less para valvular leak, um, you know, after, uh, a reduced PPM need reduced vascular complications, and, uh, decreased into, um, re-intervention rates, but no significant, uh, difference in mortality and stroke. And um you know, surgical risk, durability, patient's age are all important factors that we're considering when we're discussing um any of these uh patients in the heart team every Monday uh uh there is a heart team discussion about uh every aortic stenosis patient case that undergoes whether sour or tower. And uh you know uh we do a shared decision making for each aortic valve patient like we already discussed in those um in those uh uh you know cases on Monday but in general um. The mechanical valve is preferred in younger patients less than 50 of, of age with good life expectancy, uh, and also they have to be able to manage warfarin, of course, uh, so the staffer is kind of, you know, preferred for that those patients, um, uh, patients with age of over 80 years of age, um, again there, there's caveats now. Because patients now live longer, so you know, I've, uh, you know, if you're a, a very functional, uh, individual and you're willing to undergo the procedure and you're lower risk surg a lower surgical risk, absolutely still can get a solver, but tower is kind of what the preference right now. Anything in between, it's a shared decision making. Uh, each patient is, um, you know, you consider a lot of factors. Um, I wanted to show a case a little bit of how, um, I look at them. Aortic stenosis, um, cases on echo. So, uh, this is an 87 year old gentleman comes in with complaints of shortness of breath and headache, never seen, um, haven't seen a doctor in years. Um, and then, uh, was sent for an echo. So this is the echo, and, uh, as you see, this is parasternal, um, long axis right away, and you, this is something we don't, you know, look, look at the aortic valve. Can I, how do I point on the aortic valve, um. Pointer, yeah. So aortic aortic valve right there, um, you see how it's stiff and calcified and it's not really opening just by looking at that you're, you're suspecting that this is gonna be a severe aortic stenosis case, um, and it's not supposed to be this thick many times you don't even see the leaflets that well because, you know, they're small, um. Let me see, then you put some color Doppler and you see flow acceleration, that mosaic in the LVOT, uh, so that's another signal that you're supposed to have laminar flow there, uh, that there's something going on like probably severe aortic stenosis. Then we get a short access of the aortic valve, um, right there and then this is what the color Doppler on top of it and we're basically seeing in that same mosaic of multitude of colors in the aortic valve that's um not supposed to be there you're not supposed to see that and you see, um, a very calcified heavily calcified valve. It's not even opening. I don't even see this patient has uh a very severe aortic stenosis. Um, this is you, then you're another good view to take a look, um, scroll down, uh, to find the five chamber view, and, uh, again this is the aortic valve with the color you see the leaflets over here, they're not opening at all. Um, then you got your, um, you know, your, uh, peak velocity VM max of 4.2 here and you got your mean gradient of 45 and your aortic valve area less than 1, so that's that you basically there's a diagnosis of severe aortic stenosis in this patient. Uh, another caveats that I quickly look at sometimes as I open an echo, uh, I just look at the envelope as well. If your envelope is, uh, like, uh, late peeing like the second one, if your envelope is kind of, you know, uh, looks like broad like that with late peeing, that's usually indicative of severe aortic stenosis. If it's not late peaking, that's kind of like, OK, unlikely to be severe aortic stenosis, just kind of some of the things to look at and, um, pick up. That they can help you. So then that patient underwent um uh a tower uh implantation, and this is the tower right right there, um. And right here we check just the same thing we check in multiple views to see if there's any leakage of the tower so this patient had minimal uh what we call paravalvular regurgitation and has done very well. So, um, so in summary, aortic stenosis is a disease of an elderly. Most common causes of aortic stenosis, um, are bicuspid aortic valve stenosis or normal tricuspid aortic valve stenosis secondary to calcifications, 50 and 50%. Um, symptoms of severe aortic stenosis are, um, early symptoms are, uh, reduced exercise capacity and dyspnea on exertion. Um, heart failure, syncope, angina are late manifestations. We kinda wanna prevent that, uh, from happening, but, um, it happens, and, um, severe aortic stenosis again is defined, uh, by peak gradient over 4, mean gradient over 40, aortic valve area less than 1. And a low flow low radiant aortic stenosis, um, yeah, it, it happens when you have reduced ejection fraction with aortic valve area less than one, but the gradients, uh, that are not, um, elevated. And um thank you so much. Published June 30, 2026 Created by Related Presenters Angelina Zhyvotovska, MD Cardiology, Internal Medicine View full profile
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