Overview

Aortic valve stenosis — or aortic stenosis — is a type of heart valve disease (valvular heart disease). The valve between the lower left heart chamber and the body's main artery (aorta) is narrowed and doesn't open fully. This reduces or blocks blood flow from the heart to the aorta and to the rest of the body.

Treatment of aortic stenosis depends on the severity of the condition. You may need surgery to repair or replace the valve. Without treatment, severe aortic valve stenosis can lead to death.

Aortic valve disease

Mayo Clinic cardiologist explains aortic valve disease, including aortic stenosis.

Hello, I'm Jeremy Thaden. I'm a cardiologist at Mayo Clinic and I'd like to talk to you today about aortic valve disease. The normal aortic valve is a three leaflets structure that separates the ascending aorta from the left ventricle, which is the main pumping chamber of the heart.

During the contraction of the heart, the aortic valve typically opens three to five square centimeters. As the heart relaxes, this valve then closes and prevents leakage of blood from the ascending aorta backwards into the heart. Over the course of one's life span, the aortic valve typically opens and closes and average of several billion times.

There are two main disease categories that can affect the aortic valve during one's lifetime. The first is aortic stenosis. This is uncommon in young patients, but becomes exponentially more common as we age.

The prevalence is felt to be 6% or greater in each grade, age 75 or older here in the United States. It's felt a result from an active inflammatory process. It has microscopic features which are in some ways similar to atherosclerosis.

Risk factors for the development of aortic stenosis include high blood pressure, abnormal lipids, diabetes, and chronic kidney disease. Some individuals are felt to be genetically predisposed aortic stenosis. Aortic stenosis is in general a progressive disease. Progressive calcification of the valve results in progressive narrowing and a pressure overload phenomenon in the heart. This can cause thickening of the heart muscle and stiffening.

In early phases, this can cause shortness of breath and chest discomfort. In more advanced phases, this can cause congestive heart failure, sudden loss of consciousness, and in some cases, sudden death.

Individuals with a normal trileaflet valve typically don't experience significant narrowing until their seventies or eighties. By contrast, individuals with a congenitally abnormal valve, meaning a unicuspid or single cusp valve, or a bicuspid, a two cusp valve. These patients frequently will suffer significant narrowing of the valve earlier in life. For instance, those with bicuspid valve may suffer from significant narrowing in their fifties or sixties.

Diagnosis is often suspected based on physical examination and can be confirmed by transthoracic echocardiography. By echocardiography, we are able to determine the heart size and function, were also able to quantitate the degree of stenosis. We're able to calculate a valve area, and a mean transfer valvular gradient. A valve area less than one centimeter squared and a mean gradient greater than 40 millimeters of mercury is generally considered severe.

In select cases, we also use cardiac CT or cardiac catheterization, to better understand the severity of narrowing. Indications for operation in aortic valve stenosis include a severe degree of narrowing in conjunction with symptoms, cardiac dysfunction, or in some cases, rapid progression of the degree of narrowing.

By contrast, aortic regurgitation is a condition where there's significant leakage at the valve from the ascending aorta backwards into the heart. Instead of a pressure overload phenomenon, this results in a volume overload phenomenon. This can cause dilatation of the heart muscle as well as thickening of the heart muscle.

There are a variety of reasons why the aortic valve can leak. Most commonly, this results from a structural abnormality of the valve itself. This can be a congenitally abnormal valve like a unicuspid valve or a bicuspid valve. Alternatively, this can be an acquired condition where there's previous infection of the valve or endocarditis.

In some cases there can be significant leakage even in the setting of a structurally normal aortic valve. This is most common if there's significant dilatation of the aortic root or an ascending aneurism. Diagnosis again, is predominantly suspected based on physical examination and is confirmed by transthoracic echocardiography. Just like aortic stenosis, we're able to quantify the severity of leakage. But sometimes transesophageal echocardiography or a cardiac MRI is required to better understand the degree of leakage.

Indications for an operation and aortic valve regurgitation include severe degree of leakage in combination with symptoms: Cardiac dysfunction or significant cardiac enlargement. Aortic valve disease is in general a surgically treated disease. There are no medical options that are effective in treating either aortic stenosis or aortic regurgitation.

In most cases this requires aortic valve replacement. However, there are minority of cases where these valves can be repaired. However, in recent years, there have been increasing options available for patients with these two diseases. Recently we've developed techniques in addition to a traditional open operation. We have minimally invasive techniques such as thoracotomies that can be used to treat these diseases without an open sternotomy.

More recently, there has been development of transcatheter techniques or TAVR. This technique involves small catheters inserted typically through the groin arteries that result in replacement of the valve without midline sternotomy and without requiring the need for cardiopulmonary bypass.

Symptoms

Aortic valve stenosis ranges from mild to severe. Symptoms generally occur when narrowing of the valve is severe. Some people with aortic valve stenosis may not have symptoms for many years.

Symptoms of aortic valve stenosis may include:

  • An irregular heart sound (heart murmur) heard through a stethoscope
  • Chest pain (angina) or tightness with activity
  • Feeling faint or dizzy or fainting with activity
  • Shortness of breath, especially with activity
  • Fatigue, especially during times of increased activity
  • Rapid, fluttering heartbeat (palpitations)
  • Not eating enough (mainly in children with aortic valve stenosis)
  • Not gaining enough weight (mainly in children with aortic valve stenosis)

Aortic valve stenosis may lead to heart failure. Heart failure symptoms include fatigue, shortness of breath, and swollen ankles and feet.

When to see a doctor

If you develop symptoms that may suggest aortic valve stenosis, make an appointment with your health care provider.

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Causes

To understand the causes of aortic valve stenosis, it may be helpful to know how the heart and heart valves typically work.

The heart has four valves that keep blood flowing in the correct direction:

  • Aortic valve
  • Mitral valve
  • Tricuspid valve
  • Pulmonary valve

Each valve has flaps (cusps or leaflets) that open and close once during each heartbeat. Sometimes, the valves don't open or close properly. If a valve doesn't fully open or close, blood flow is reduced or blocked.

In aortic valve stenosis, the valve between the lower left heart chamber (left ventricle) and the aorta does not open completely. The area through which blood moves out of the heart to the aorta is narrowed (stenosis).

When the aortic valve opening is narrowed, the heart must work harder to pump enough blood into the aorta and to the rest of the body. The extra work of the heart can cause the left ventricle to thicken and enlarge. Eventually the strain can cause a weakened heart muscle and can ultimately lead to heart failure and other serious problems.

Aortic valve stenosis causes include:

  • Congenital heart defect. Some children are born with an aortic valve that has only two cusps (bicuspid aortic valve) instead of three (tricuspid aortic valve). Rarely, an aortic valve may have one (unicuspid) or four (quadricuspid) cusps.

    Having a congenital heart defect such as a bicuspid aortic valve requires regular medical checkups. The valve condition may not cause any problems until adulthood. If the valve begins to narrow or leak, it may need to be repaired or replaced.

  • Calcium buildup on the valve (aortic valve calcification). Calcium is a mineral found in the blood. As blood repeatedly flows over the aortic valve, calcium deposits can build up on the heart valves.

    The calcium deposits may never cause any problems. Aortic valve stenosis that's related to increasing age and calcium deposit buildup usually doesn't cause symptoms until age 70 or 80. However, in some people — particularly those with congenital aortic valve defects — calcium deposits result in stiffening of the valve cusps at a younger age.

  • Rheumatic fever. This complication of untreated strep throat can damage the heart valves. It may cause scar tissue to form on the aortic valve. Scar tissue can narrow the aortic valve opening or create a rough surface on which calcium deposits can collect.

    Rheumatic fever may damage more than one heart valve, and in more than one way. While rheumatic fever is rare in the United States, some older adults had rheumatic fever as children.

Risk factors

Risk factors of aortic valve stenosis include:

  • Older age
  • Certain heart conditions present at birth (congenital heart defects), such as a bicuspid aortic valve
  • Chronic kidney disease
  • Having heart disease risk factors, such as diabetes, high cholesterol and high blood pressure
  • History of infections that can affect the heart, such as rheumatic fever and infective endocarditis
  • History of radiation therapy to the chest

Complications

Aortic valve stenosis can cause complications, including:

  • Heart failure
  • Stroke
  • Blood clots
  • Bleeding
  • Irregular heart rhythms (arrhythmias)
  • Infections that affect the heart, such as endocarditis
  • Death

Prevention

Some possible ways to prevent aortic valve stenosis include:

  • Taking steps to prevent rheumatic fever. See your health care provider when you have a sore throat. Strep throat can usually be easily treated with antibiotics. Untreated strep throat can develop into rheumatic fever. Rheumatic fever is more common in children and young adults.
  • Keeping the heart healthy. Talk to your health care provider about risk factors for heart disease and how to prevent or manage them. They include high blood pressure, obesity and high cholesterol levels. These risk factors may be linked to aortic valve stenosis.
  • Taking care of the teeth and gums. There may be a link between infected gums (gingivitis) and infected heart tissue (endocarditis). Inflammation of heart tissue caused by infection can narrow arteries and worsen aortic valve stenosis.

If you have aortic valve stenosis, your health care provider may recommend that you limit strenuous activity to avoid overworking your heart.

Aortic valve stenosis care at Mayo Clinic

Aug. 18, 2022
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