Aortic Valve Stenosis

Aortic valve stenosis is a heart condition where the valve controlling blood flow from your heart to your body becomes narrowed and stiff, making your heart work much harder and potentially leading to serious complications if left untreated.

Table of contents

• What is aortic valve stenosis?
• What causes this condition?
• Recognizing the symptoms
• How doctors diagnose aortic valve stenosis
• Treatment options
• Living with aortic valve stenosis

What is aortic valve stenosis?

Your heart has four valves that act like one-way doors, controlling blood flow in the right direction. The aortic valve sits between the lower left chamber of your heart and the aorta, which is the main artery carrying blood to the rest of your body^[1]. This valve normally has three flaps, called leaflets, that open to let blood pass through and then seal shut to prevent blood from flowing backward^[3].

In aortic valve stenosis, this valve becomes narrowed and doesn’t open fully. When the valve opening narrows, it becomes harder for your heart to pump blood through to your body^[1]. Think of it like trying to water a garden with a kinked hose – that’s similar to what happens in your heart with this condition^[21]. Because the condition restricts blood flow, it also limits how much oxygen your body receives, which can cause chest pain, shortness of breath, and fainting^[3].

Aortic stenosis is common in people over 65 years old. The prevalence increases significantly with age – about 6% or more of people aged 75 or older have this condition^[1][4]. Many people don’t know they have it until symptoms appear or until it shows up during a routine medical examination^[3].

What causes this condition?

Aortic stenosis in adults has three main causes. The first and most common is wear and tear due to aging. Over time, calcium can build up on the valve, making it thick and stiff, which limits blood flow. This type of stenosis happens most commonly after age 65^[3]. Interestingly, the condition shares similarities with atherosclerosis, involving processes such as lipid accumulation, inflammation, and calcification^[12].

The second cause is damage from infections. When bacteria from untreated infections reach your bloodstream, they can accumulate on your heart valves, causing your immune system to damage the valve itself^[3]. This is most likely to happen with strep throat or scarlet fever that goes untreated. These infections can lead to rheumatic fever, a disease that can damage heart valves. In developing countries, rheumatic valve disease remains the most common cause of aortic stenosis^[4]. The damage may take years or even decades before becoming apparent^[3].

The third category includes congenital (present at birth) conditions and other inherited or chronic conditions. Some people are born with a bicuspid aortic valve, meaning the valve has only two leaflets instead of the normal three. This is the most common cause of aortic stenosis in patients less than 70 years old in developed countries^[4]. Other rare conditions that can cause aortic stenosis include Paget’s disease of the bone, kidney failure, and familial hypercholesterolemia. The condition is also linked to autoimmune or inflammatory diseases like lupus and rheumatoid arthritis^[3].

Several risk factors increase the likelihood of developing aortic valve stenosis. Being male and being older than 65 are significant risk factors^[3]. Other factors include smoking, high blood pressure, high cholesterol, and chronic kidney disease^[8].

Recognizing the symptoms

Aortic stenosis typically has a long period without symptoms, often lasting 10 to 20 years^[4]. During this time, your heart adapts by developing thicker walls to help maintain adequate blood flow. However, as the valve becomes more narrowed, these adaptations become inadequate, and symptoms begin to appear^[12].

Symptoms often come on with exercise or physical activity. The progression typically moves from less severe to more severe symptoms^[3]. Early symptoms include fatigue that disrupts normal activities and heart palpitations, which is when you become unpleasantly aware of your own heartbeat^[3]. Some people also notice tiredness and shortness of breath^[8].

As the condition worsens, symptoms become more serious. These include chest pain, which can also feel like squeezing, pressure, or discomfort that may extend to your neck, jaw, arm, or abdomen. This type of chest pain is called angina^[3]. People may also experience shortness of breath, dizziness, lightheadedness, or fainting spells^[3][8]. Swelling in the feet, ankles, or lower legs can also occur^[3].

The development of symptoms marks a critical turning point. Without treatment, the average survival after symptoms develop is only about 2 to 3 years^[21]. Older adults who typically have decreased activity levels may experience a delayed onset of symptoms or relate their symptoms to other coexisting conditions^[13].

How doctors diagnose aortic valve stenosis

Often, aortic stenosis is first suspected when a doctor hears an unusual sound called a heart murmur while listening to your heart with a stethoscope during a routine physical examination^[6][19]. Your doctor will also ask about your symptoms and medical history and perform a physical examination^[9].

The most important test for diagnosing aortic stenosis is an echocardiogram, which uses sound waves to create pictures of your beating heart^[9]. This test shows how blood flows through your heart and heart valves and can determine how severe the stenosis is. It also shows if the heart muscle has been weakened^[9]. There are different types of echocardiograms. A standard one is done from outside the body, with an ultrasound device moved over the skin of the chest. If more details are needed, a transesophageal echocardiogram may be performed, where the ultrasound device is passed down the throat and into the esophagus to get pictures from inside the body^[9].

Other tests that may be performed include an electrocardiogram (ECG or EKG), which records the electrical activity of the heart and can detect signal patterns related to heart disease or swelling of the heart’s chambers^[9]. A chest X-ray can show if the heart is bigger than usual, which can occur in aortic valve stenosis^[9]. In some cases, doctors may also perform cardiac catheterization, a more invasive test, particularly if you’re being evaluated for valve replacement surgery^[6].

For patients without symptoms, doctors often recommend a stress test. If the stress test shows a problem or if you have symptoms, cardiac catheterization may be done to check if you also have coronary artery disease, since doctors can fix your coronary arteries at the same time if you need valve surgery^[6].

Treatment options

The treatment approach for aortic stenosis depends on whether you have symptoms and how severe the condition is. Aortic valve replacement is the only treatment that improves survival in patients with symptomatic severe aortic stenosis^[12]. Without treatment, severe aortic valve stenosis can lead to life-threatening complications^[1].

For adults with aortic stenosis who don’t have symptoms, doctors typically recommend watchful waiting^[12]. During this time, you should see your doctor regularly, avoid overly stressful exercise, and have periodic echocardiograms as your doctor recommends^[6]. The frequency of follow-up echocardiograms depends on severity: every six to 12 months for severe aortic stenosis, every one to two years for moderate disease, and every three to five years for mild disease^[12].

When symptoms develop or the left ventricle begins to fail, valve replacement becomes necessary. There are two main approaches for replacing the aortic valve.

The first is surgical valve replacement, which is the standard of care for patients at low to moderate surgical risk^[12]. This involves open-heart surgery where doctors make an incision down the center of the chest and temporarily stop the heart while replacing the valve^[21]. You can receive either a mechanical valve made of plastic and metal, or a bioprosthetic valve made from pig or cow heart tissue^[6]. If you get a mechanical valve, you’ll need to take blood-thinning medicine for the rest of your life, but the valve may last several decades. If you get a bioprosthetic valve, you’ll only need blood-thinning medicine for a few months, but the valve typically lasts only 10 to 12 years^[6].

A newer approach is minimally invasive “keyhole” surgery, which allows doctors to replace the valve through much smaller incisions between the ribs instead of opening the entire chest^[21]. This approach offers smaller incisions, less post-operative pain, and faster recovery times – many patients go home in just 3 to 4 days. Recent advancements have reduced recovery time from 3 months to just 3 weeks for many patients^[21].

The second major approach is Transcatheter Aortic Valve Replacement (TAVR), also called Transcatheter Aortic Valve Implantation (TAVI). This is a truly revolutionary procedure that allows doctors to replace the aortic valve without open-heart surgery^[15][21]. During TAVR, a doctor inserts a thin tube called a catheter through a small incision, usually in the groin, and guides it up to the heart. The catheter contains a new valve that is positioned and expanded at the site of the diseased valve^[15]. Because it’s minimally invasive, TAVR patients can recover more quickly and spend less time in the hospital^[15].

TAVR was initially developed for people who weren’t healthy enough for open-heart surgery. After studies proved it was safe and effective, heart specialists now recommend it as the first option for most people who need an aortic valve replacement^[19]. It’s recommended for patients at prohibitive surgical risk and is a reasonable alternative to surgical replacement for high-risk patients^[12].

Children and young adults born with valve problems may have a procedure called balloon valvotomy. The doctor inflates a balloon on the tip of a catheter to push the valve open. However, this procedure doesn’t work very well for older adults^[6].

Living with aortic valve stenosis

Patients with aortic stenosis can live full and rewarding lives, though they may need to be monitored by a heart specialist with office visits and periodic testing^[16]. Many patients discover they have aortic stenosis before they develop any symptoms. These patients need to watch for certain warning signs such as chest pain or discomfort, difficulty breathing, or lightheadedness or fainting spells, and should report any of these symptoms immediately to their doctor^[16].

Based on the severity of your condition, your doctor may limit your activity, but many patients can exercise and do most activities without restriction. However, you should increase activity or start an exercise program only under your doctor’s guidance^[16]. If you’re an adult with aortic stenosis but don’t have symptoms, you should avoid overly stressful exercise^[6].

Several lifestyle measures can help protect your heart health. Eating heart-healthy foods is important – these include vegetables, fruits, nuts, beans, lean meat, fish, and whole grains. You should limit sodium, alcohol, and sugar^[3]. Staying at a healthy weight and losing weight if needed is beneficial^[3]. If you smoke, quitting is crucial^[3].

Managing other health problems is also important. If you have high blood pressure or high cholesterol, working with your doctor to control these conditions helps^[3]. Getting vaccinated against COVID-19, influenza (flu), and pneumonia is recommended^[3]. Taking care of your teeth and gums through good dental hygiene and regular dental checkups is important because bacteria can spread from infected teeth and gums to the heart valves^[3].

If you’re being monitored without treatment, you’ll work with your heart specialist to set a schedule for monitoring and testing. Together, you’ll decide when and if treatment is needed^[16]. Because aortic stenosis tends to progress over time, even patients without symptoms require routine testing to monitor their condition^[16].

After valve replacement surgery, whether through traditional surgery or TAVR, most patients experience significant improvement. Recovery timelines vary by individual and the type of procedure performed. Many people can resume light desk work within 2 to 4 weeks and driving within 2 to 4 weeks once they’re no longer taking pain medications^[20]. With proper treatment and care, patients can often have their life expectancy restored to nearly normal for their age^[21].