Snapshot A 74-year-old man reports a 3-month history of intermittent chest pain, syncopal episodes, and dyspnea on exertion. He has a long-standing history of coronary artery disease and hypertension. Physical exam reveals a systolic crescendo-decrescendo murmur, heard best at the heart base and radiates to the carotids. He is sent for further evaluation with an echocardiogram. Introduction Clinical definition narrowing of the aortic valve Associated conditions hemolytic anemia Etiology Age-related dystrophic calcification of normal (tricuspid) aortic valve in older patients Calcification of bicuspid aortic valve in younger patients Pathogenesis atherosclerosis can lead to plaque formation and calcium deposits on the aortic valve aortic stenosis results in ↑ left heart pressure → left ventricular hypertrophy (LVH) LVH and stiff, noncompliant walls result in ↑ oxygen demand and clinically manifests as angina over time, aortic stenosis results in ↓ blood flow to the vertebral, basilar, and carotid arteries, resulting clinically in syncope Epidemiology Demographics bicuspid aortic valve calcification presents at a younger age tricuspid aortic valve calcification > 65 years of age Risk factors hypertension coronary artery disease rheumatic heart disease Presentation Symptoms heart failure SAD Syncope Angina or chest pain (most common) Dyspnea Physical exam systolic ejection murmur heard best at heart base may have ejection click radiates to carotid arteries crescendo-decrescendo murmur decreases with standing, Valsalva, or handgrip increases with amyl nitrate, squat, or leg raise single, soft S2 suggestive of severe aortic stenosis S4 heart sound from stiff or hypertrophic ventricle paradoxical splitting of S2 heard on expiration rather than inspiration pulsus parvus et tardus weak pulses with a delayed peak Imaging Radiography indication for all patients findings cardiomegaly calcification pulmonary congestion Echocardiography indications for all patients diagnostic test views transthoracic echocardiogram (TTE) initially transesophageal echocardiogram (TEE) is more accurate findings thick aortic valve leaflets aortic valve anatomic abnormalities LVH Studies Electrocardiogram (ECG) indications for all patients findings LVH Left heart catheterization indications most accurate diagnostic test to assess pressure gradient across the valve only indicated to confirm the diagnosis if echocardiography is unclear findings elevated pressure gradient (> 30 mmHg) Differential Hypertrophic cardiomyopathy distinguishing factor normal aortic valve on echo and murmur that does not radiate to the carotids Diagnosis Making the diagnosis based on clinical presentation and echocardiogram Treatment Medical diuretics indication best initial therapy for all patients with pulmonary congestion Operative aortic valve replacement indication definitive treatment if patients are symptomatic if aortic valve area is < 0.8 cm2 (normal 2.5-3 cm2) if ejection fraction < 50% modalities bioprosthetic valves require more frequent replacement but do not require anticoagulation mechanical valves are not replaced as often but must be treated with anticoagulation balloon valvuloplasty indication in patients too ill for surgery Complications Arrhythmia Heart failure Endocarditis Prognosis Often asymptomatic Once symptomatic, most patients require aortic valve replacement