Aortic Valve DiseaseHere is a basic understanding of aortic valve disease
Aortic valve disease can present at any age and is often fairly advanced at diagnosis. However not all patients require immediate surgery and can be managed on medications for a considerable period of time.
The aortic valve is a 3 leaflet structure that guard’s the outlet of the left ventricle, the main pumping chamber of the heart. Its function is to prevent blood from getting back into the left ventricle once it has been pumped out.
Aortic valve disease can present itself at birth (congenital) or can be acquired. The most common causes of aortic valve disease is usually degenerative or secondary to a sore throat caused by bacterial infection (Rheumatic heart disease). Irrespective of cause, aortic valve disease presents as two variants or a combination of both variants.
Normal Aortic Valve
Aortic incompetence or regurgitation
Often referred to as AR in short, this condition is secondary to the valve cusps not coapting or coming together to prevent blood from flowing back into the left ventricle after its been ejected out. Most patients are either diagnosed accidentally at an early stage or can present at a late stage with a dilated ventricle and associated heart failure. Aortic regurgitation can occur because of leaflet pathology or aortic root disease.As an isolated lesion, aortic regurgitation usually occurs because of a congenital bicuspid aortic valve, often resulting from leaflet prolapse. Examples include diseases of the aortic root, such as annuloaortic ectasia, long standing hypertension, familial aortic aneurysmal disease, and hereditable diseases of connective tissue, such as Marfan syndrome. Additionally, ascending aortic dissections and congenital diseases, such as ventricular septal defects as seen in tetralogy of Fallot, can lead to aortic regurgitation. Other less common conditions include radiation heart disease, Ehlers-Danlos syndrome, and inflammatory aortitis and/or aortic valvulitis caused by giant cell aortitis, reactive arthritis, syphilitic aortitis, ankylosing spondylitis, and rheumatoid arthritis.
The valve orifice opening becomes progressively narrowed due to fusion of leaflets and calcification. This is usually a degenerative process but the degeneration could be more rapid in valves that are deformed at birth. The presentation therefore can occur at any age group but most patients are usually into their 5th or 6th decade. The most common symptoms are usually fatigue, shortness of breath on exercise and even chest pain. Some patients may even present for the first time with sudden heart failure and pulmonary edema. Death can result as well if the heart loses its rhythm.
Diseased Aortic Valve
Medical treatment of Aortic Valve Disease
When diagnosed early medication may have a role in managing aortic valve disease. Medication may play a large role in delaying surgery in those diagnosed with aortic incompetence in particular. Its important to note that medication has a limited role and is of no benefit in advanced disease.
When should one choose surgery?
The decision to choose surgery for treating aortic valve disease is done in consult with your medical care team which should comprise of a heart surgeon and cardiologist. The recommendation is based on several factors including symptoms as well as various investigations such as an echocardiogram and angiogram. The ECHO will help assess the degree of stenosis or regurgitation, will show enlargement of the heart if any as well other coexistent anomalies. The angiogram will show this in addition to blocks in the vessels supplying the heart if any.
Surgical AVR (Aortic Valve Replacement) is the gold standard for effective treatment of severe aortic valve disease. It has been proven to provide symptomatic relief and long term survival in adults. During the procedure the native valve is removed and replaced with an appropriately sized artificial valve. Surgical AVR is recommended in all adult patients who do not have other medical conditions that prevents them from undergoing the procedure.
Surgical treatment options for Aortic Valve Disease
Three treatment options exist for surgical Aortic valve replacement
- Traditional replacement: The breast bone is cut in full to access the heart and the aortic valve replaced
- Minimally Invasive Cardiac Surgical Technique that allow for the valve to be replaced via a small incision. Two techniques exist
- Upper hemisternotomy
- Parasternal approach – more superior, no bones are cut
- Trans catheter aortic valve replacement (TAVR) in selected patients not suited for the above procedures.
Aortic valve disease in those over 75
Percent of patients who would die if left untreated within two years after the onset of symptoms
Patients not referred to a surgeon after diagnosis of aortic stenosis
Diagnosing Aortic Valve Disaese
- Clinical Examinations: Your heart surgeon or cardiologist can hear abnormal heart sounds called a murmur on examining your heart with a stethescope
- ECG or Electrocardiogram
- Chest Xray
- Echocardiogram: This is the most frequently performed and the most reliable investigation to diagnose the condition as well as to estimate the severity of the disease. Often no other tests are required once an ECHO is done
Symptoms of Aortic Valve Disease
- Giddiness or Lightheadedness
- Chest pain or tightness
- Difficulty in breathing often at rest
- Difficulty exercising
- Irregular heart beats