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Aortic valve disease

Specialties > Peri-op medicine & anaesthesia

Background knowledge 🧠

Definition

  • Aortic valve disease encompasses a range of conditions affecting the aortic valve, leading to either stenosis (narrowing) or regurgitation (leakage).
  • The aortic valve controls blood flow from the left ventricle to the aorta.
  • Can be congenital or acquired.

Epidemiology

  • Prevalence increases with age; most common in the elderly.
  • Aortic stenosis is more common than aortic regurgitation.
  • More prevalent in males.
  • In the UK, calcific aortic stenosis is the most common form.

Aetiology and pathophysiology

  • Degenerative (calcific) changes – most common cause of aortic stenosis.
  • Rheumatic heart disease – can lead to both stenosis and regurgitation.
  • Congenital bicuspid aortic valve – increases risk of both stenosis and regurgitation.
  • Aortic root dilatation – common cause of aortic regurgitation.

Types

  • Aortic stenosis – narrowing of the valve leading to obstruction of blood flow.
  • Aortic regurgitation – incompetence of the valve leading to backflow of blood into the left ventricle.
  • Mixed aortic valve disease – both stenosis and regurgitation present.

Clinical Features 🌡️

Symptoms

  • Dyspnoea on exertion – common in both stenosis and regurgitation.
  • Angina – particularly in aortic stenosis.
  • Syncope – classically associated with severe aortic stenosis.
  • Fatigue – more pronounced in aortic regurgitation.
  • Palpitations – may occur in aortic regurgitation.
  • Orthopnoea and paroxysmal nocturnal dyspnoea in advanced cases.

Signs

  • Ejection systolic murmur – heard at the right upper sternal border (aortic stenosis).
  • Early diastolic murmur – heard at the left lower sternal border (aortic regurgitation).
  • Slow-rising pulse (pulsus parvus et tardus) in aortic stenosis.
  • Corrigan’s pulse (collapsing pulse) in aortic regurgitation.
  • Signs of heart failure – peripheral oedema, raised JVP.

Investigations 🧪

Tests

  • Echocardiography – gold standard for diagnosis, assessing severity.
  • ECG – may show left ventricular hypertrophy, conduction abnormalities.
  • Chest X-ray – cardiomegaly, aortic root dilatation.
  • Cardiac MRI – useful in complex cases.
  • Cardiac catheterisation – used in selected cases for haemodynamic assessment.
  • Blood tests – BNP may be elevated in heart failure.

Management 🥼

Management

  • Medical – symptom control with diuretics, vasodilators (for regurgitation).
  • Surgical – aortic valve replacement (AVR) is definitive treatment.
  • Transcatheter aortic valve implantation (TAVI) – alternative for high-risk surgical patients.
  • Endocarditis prophylaxis – important in patients with prosthetic valves.
  • Lifestyle – control of cardiovascular risk factors (e.g., hypertension, hyperlipidaemia).

Complications

  • Heart failure – due to chronic pressure or volume overload.
  • Arrhythmias – atrial fibrillation is common, particularly in regurgitation.
  • Infective endocarditis – particularly in those with prosthetic valves.
  • Sudden cardiac death – rare but can occur in severe aortic stenosis.
  • Post-operative complications – including valve dysfunction, thromboembolism.

Prognosis

  • Aortic stenosis – poor prognosis if symptomatic and untreated.
  • Aortic regurgitation – better prognosis if asymptomatic, but deteriorates once symptoms develop.
  • Early surgical intervention improves outcomes.
  • TAVI offers a good alternative in selected patients.

Key points

  • Echocardiography is key in diagnosis and monitoring.
  • Symptomatic aortic stenosis requires prompt surgical referral.
  • TAVI is an option for those who are not surgical candidates.
  • Medical management is supportive; definitive treatment is surgical.
  • Regular follow-up is essential to monitor for progression.

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Peri-op medicine & anaesthesia