Aortic stenosis

At Aortic stenosis the transition between the heart and aorta is narrowed due to damage to the heart valve. The heart has to use more force to pump the blood through the constriction, and without therapy, it will suffer long-term damage.

What is aortic stenosis?

Aortic stenosis is a heart valve defect that narrows the outflow tract of the left ventricle (left ventricle). As a result of the narrowing (stenosis) the left heart is subjected to pressure, which in many cases leads to left heart failure.

Symptoms of aortic stenosis are dizziness, shortness of breath and syncope (fainting) during exercise, cardiac arrhythmias and angina pectoris attacks. Depending on the localization of the stenosis, a distinction is made between three forms of the disease. The so-called valvular stenosis is characterized by a narrowing of the aortic valve (typical aortic stenosis).

In a supravalvular stenosis, the narrowing is above the aortic valve. The so-called subvalvular stenosis is caused by a membranous thickening of the outflow tract or a hypertrophic obstructive cardiomyopathy (thickening of the muscles of the left ventricle).

causes

A general distinction is made between degenerative (acquired) and congenital (congenital) aortic stenoses. Congenital stenoses can usually be traced back to morphological anomalies (malformations) of the heart valve.

The affected valve can consist of two valve leaflets instead of three (bicuspid aortic valve), which only allow a small opening. Affected between 40 and 60 years of age mostly suffer from acquired valve stenosis. This can manifest itself as a result of rheumatic fever or bacterial endocarditis (inflammation of the lining of the heart).

In people aged 60 and over, the majority of the disease can be traced back to aortic sclerosis (calcifying valve stenosis or senile form). Additional risk factors for acquired aortic stenosis are smoking, renal insufficiency (decreased kidney function), hypercalcaemia (increased calcium concentration in the blood), high blood pressure and diabetes mellitus.

Symptoms, ailments & signs

In the worst case, the aortic stenosis can lead to death. However, this case usually only occurs if the aortic stenosis is not treated. Since this does not lead to self-healing, those affected are dependent on treatment in any case. The patients suffer primarily from a strong feeling of dizziness and also from shortness of breath.

In severe cases, this can lead to a loss of consciousness, which can also injure the person concerned. Loss of consciousness can also occur without physical exertion. Due to the aortic stenosis, many sufferers also suffer from disorders of the heart rhythm and thus from heart pain.

Without treatment, this ultimately leads to permanent damage to the heart and also to sudden cardiac death. The surrounding vessels are also damaged by the aortic stenosis, so that further disease can develop without treatment. The patients often appear exhausted and tired, although this tiredness cannot be counteracted with the help of sleep. This also significantly reduces the patient's resilience. In many cases, the limitations in everyday life also lead to psychological complaints, so that patients with aortic stenosis are dependent on psychological treatment.

Diagnosis & course

In auscultation, a noise can be heard during the contraction phase due to the changed hemodynamics (flow dynamics of the blood) (systolic heart murmur). In the differential diagnosis, aortic stenosis must be differentiated from mitral valve insufficiency, pulmonary stenosis and ventricular septal defects by further examinations.

An echocardiography can determine left heart hypertrophy and a fibrotic thickened or calcified valve with reduced mobility. In addition, a chest x-ray shows an enlarged aorta (aortic dilation and elongation). The valve opening area and the pressure gradient can be determined by means of a color Doppler echocardiography and cardiac catheter examination.

At first, aortic stenoses are mostly asymptomatic. The initial symptom is usually exertional dyspnea (exertional dyspnoea) with syncope. Since the upstream sections of the heart have to exert more force in order to pump the blood through the constriction into the large body circulation, the heart muscle thickens as it continues and requires more oxygen. The coronary vessels supplying these are, however, located after the narrowing.

This leads to a reduced blood flow and further damage to the heart muscle (left heart failure). About a fifth of those affected die as a result of sudden cardiac death from ventricular fibrillation or AV blockages (atrioventricular conduction disorder). In those affected by surgery, the 10-year survival rate is more than 65 percent. If left untreated, the prognosis for aortic stenosis is poor.

Complications

Complications that can arise as a result of untreated aortic stenosis are ultimately caused by the difficult flow of blood through the aortic valve. The congenital or later acquired reduced passage cross-section in the area of ​​the aortic valve causes a reduced supply of the entire body including the brain.

This is especially noticeable after physical exertion. Shortness of breath, exhaustion and short-term fainting attacks (syncope) can result. On the other hand, the heart tries to compensate for the insufficient supply of the body with arterial blood by increasing the pumping capacity of the left ventricle. As a result, the heart muscle in the left ventricle thickens and requires more oxygen.

As a rule, however, this does not work because the supplying coronary arteries only branch off behind the stenosis. Typically, in the case of untreated aortic stenosis, in addition to dizziness, shortness of breath and short fainting attacks as a result of the insufficient supply, other complications such as cardiac arrhythmias and coronary heart diseases arise. The most common cardiac arrhythmia in this context is so-called atrial fibrillation.

In uncoordinated atrial contractions at a high frequency, this is not immediately life-threatening, but it leads to significant performance losses and can be very uncomfortable. The complications described above can largely be avoided by treating the aortic stenosis. Apart from the surgical risk and the possible requirement to have to take coagulation inhibitors (blood thinners) for life, no other complications are to be expected.

When should you go to the doctor?

If you experience cardiac arrhythmias, dizziness or swelling in the limbs, you should immediately consult your family doctor or a cardiologist. If there is a specific suspicion of aortic stenosis, the doctor can perform an echocardiography and rule out the disease or determine it beyond doubt. Ideally, the disease is diagnosed at an early stage, i.e. when the first symptoms such as increasing shortness of breath, oppression and tightness of the chest. Anyone who notices these symptoms should speak to their family doctor directly.

In the early stages, aortic stenosis can usually be corrected before serious complications develop. A doctor's visit is necessary at the latest when swelling of the ankles and lower legs, severe shortness of breath and heart palpitations occur. Although complications have often arisen by then, serious illnesses such as blood clots and heart failure can still be avoided.In general, aortic stenosis should be diagnosed and treated as early as possible. Regular consultation with the cardiologist should also be held after treatment. This enables abnormalities to be clarified promptly and serious consequences to be avoided.

Doctors & therapists in your area

Treatment & Therapy

The treatment strategy for aortic stenosis depends on the severity of the disease. For mild and asymptomatic stenoses, conservative drug therapy with diuretics and digitalis (cardiac glycosides) may initially be sufficient.

Those affected should generally avoid heavy physical exertion. Endocarditis prophylaxis is indicated to reduce the risk of bacterial infection of the damaged valves. This includes that those affected seek medical advice as soon as possible at the first signs of an infectious disease (including fever) so that antibiotic therapy can be initiated at an early stage. In addition, antibiotic therapy should be carried out in advance of surgical interventions (including dental operations) to avoid infection.

With the majority of those affected, surgical intervention is essential to avoid left heart failure. Valve replacement surgery is usually performed, especially in the case of acquired stenoses. Mechanical prostheses made of plastic or metal, biological prostheses (usually prepared pig valves) or human valve transplants can be used as valve replacement.

If artificial valves are used, lifelong anticoagulation (medicinal anticoagulation) is required. In addition, balloon dilation of the aortic valve via a cardiac catheter may be indicated in the case of congenital stenoses. Here, the damaged valve is expanded and at the same time fused valves are burst open. In children with congenital aortic stenosis, the damaged valves are increasingly removed and replaced by the body's own pulmonary valves.

Unlike artificial valves, these grow with the child's organism in a normal rhythm and enable normal loads and sporting activities after the operation. The transplanted pulmonary valves are replaced by foreign human valves (homograft). Regular follow-up examinations are required in all cases.

Outlook & forecast

People who have aortic stenosis often have no symptoms for years. If symptoms then arise, consequential damage to the heart has often already developed. Most patients also suffer from various concomitant diseases such as anemia, hypertension or COPD, which superimpose the symptoms of the heart.

If aortic stenosis is not treated, this can lead to serious consequences, since blood clots can then form on the calcified aortic valve due to blood flow and reach the brain. If they clog a vessel there, the blood supply is cut off and the patient suffers a stroke. An untreated aortic stenosis can also lead to cardiac arrhythmias, ventricular fibrillation and even death.

With surgical treatment, however, the prognosis for aortic stenosis is very good. The prognosis differs from patient to patient, however, as it depends on the general condition or the severity of the illness as well as any accompanying illnesses. By replacing the aortic valve, the prognosis could be significantly improved, so that especially older patients with aortic stenosis are now the same age as people who do not suffer from aortic stenosis.

prevention

The best possible prophylaxis for degenerative stenoses is to reduce the risk factors. On the one hand, nicotine consumption should be avoided and, on the other hand, diseases such as rheumatic fever, diabetes mellitus, endocarditis, renal insufficiency and high blood pressure should be treated adequately and at an early stage. Congenital aortic stenosis, however, cannot be prevented.

Aftercare

Severe forms of aortic stenosis require surgery, which means regular follow-up exams. The family doctor is an important point of contact. He will arrange blood tests and electrocardiograms. Sometimes a cardiologist is called in as part of the follow-up care.

Examinations are carried out at short intervals immediately after the operation. After several years without complaints, an annual follow-up examination is sufficient. On the other hand, mild forms of aortic stenosis do not require any special therapy. Patients should only avoid physical stress. Immunity to heart problems does not build up after aortic stenosis has been treated. This forces those affected to be less careful in everyday life.

The sick person plays an important role. He must be aware of the warning signs on his body and consult a doctor if necessary. Fever, infections and a tendency to bleed can affect the heart. Endocarditis is a risk after heart surgery.

If left untreated, it can lead to death. In everyday life you should avoid stress and, if necessary, take it easy on your job. Cigarette consumption is considered extremely harmful to the heart. You should therefore completely avoid nicotine. During the initial diagnosis, a doctor provides information about the everyday consequences.

You can do that yourself

A diagnosed aortic stenosis, synonymous with aortic valve stenosis, is assigned to one of three degrees of severity: mild, moderate or severe. While general symptoms such as shortness of breath when exerted, fainting or pain in the chest area cannot be overlooked in the severity grades medium and high, no subjective symptoms are usually recognizable in the case of mild aortic valve stenosis.

Despite the valve defect, sporting activities are recommended to strengthen and stabilize the cardiovascular system. With mild aortic stenosis, there are no restrictions on exercise, provided that no further symptoms occur while exercising. In the case of moderate aortic valve stenosis, endurance sports should be exercised without uncontrollable peak loads. Hiking, Nordic walking, cycling, swimming and playing golf on courses that are as level as possible are particularly suitable.

Most ball sports, in which peak loads can hardly be controlled, are not well suited. Stressing the cardiovascular system and exercising as a self-help measure lead to an improved general well-being. However, it is very likely that the activities are unlikely to have any effect on the further course of the disease.

If there is a high degree of valve stenosis, physical activity is hardly possible because the performance restrictions are too severe and any performance demands can lead to acute problems. In severe cases of aortic stenosis, neither self-help measures nor medication are effective, so appropriate surgical or corrective interventions should be considered.