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CHAPTER SUMMARY AND CENTRAL ILLUSTRATION

Chapter Summary

This chapter discusses the epidemiology, pathophysiology, diagnosis, and management of calcific aortic valve stenosis (AS), a progressive fibro-calcific remodeling of the aortic valve leaflets that eventually impairs leaflet mobility and significantly obstructs blood flow. In high-income countries, AS is the third-most-frequent cardiovascular disease, with a prevalence of up to 5% in those aged >65 years. The first suspicion of AS is often raised by auscultation of a systolic murmur. Confirmation and evaluation of the disease are based on Doppler-echocardiography but may require an additional imaging modality in association with blood biomarkers. In addition to assessing the valve lesion and dysfunction, evaluating the AS-associated damage to the left ventricle and other cardiac chambers is essential to optimize risk stratification and therapeutic decision-making. Routine clinical and Doppler-echocardiography follow-up should be performed every 1–2 years to detect changes in AS severity, left ventricular systolic function, and/or the patient’s symptomatic status. No pharmacological approach has yet proven effective to slow the progression of AS. Patients with severe AS and symptoms or left ventricular systolic dysfunction should be considered for aortic valve replacement (see Fuster and Hurst’s Central Illustration). The decision to intervene and the choice of surgical versus transcatheter intervention should involve patients, referring physicians, and a multidisciplinary heart team.

eFig 28-01 Chapter 28: Aortic Stenosis

INTRODUCTION

Calcific aortic valve disease is a slowly progressive disease that starts with mild fibrosis, calcification and thickening of the valve leaflets without obstruction of blood flow, ie. aortic sclerosis.1 This disease then evolves over the years to severe calcification with impaired leaflet mobility and significant obstruction to blood flow, ie. aortic stenosis (AS). Doppler-echocardiography is the method of choice for the diagnosis and follow-up of AS and multi-modality imaging provides incremental value for the risk stratification and management of the disease. The natural history of AS is characterized by a long latent period during which, the stenosis progresses in stages from mild, to moderate, to severe, and the patient usually remains asymptomatic in the early stages. However, once cardiac symptoms develop in a patient with severe AS, the prognosis in the absence of treatment is extremely poor with 40% to 50% all-cause mortality at 2 years.1 There are currently no validated pharmacotherapies that can halt or delay the progression of AS or its resulting adverse effects on cardiac function and patient outcomes. Hence, aortic valve replacement (AVR) currently is the sole effective option for the treatment of severe AS. In the past 15 years, transcatheter AVR (TAVR) has emerged as an alternative to surgical AVR (SAVR) in appropriately selected patients.

EPIDEMIOLOGY, ETIOLOGY, AND PATHOPHYSIOLOGY

Calcific aortic valve disease is, by far, the most prevalent form of AS in high income countries. In low-income countries, AS may also be caused by rheumatic ...

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