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Aortic Valve Disease
The most common indication for valve surgery on the aortic valve is calcific or degenerative valve calcification. This calcification is similar to atherosclerotic coronary disease and shares many of the same risk factors. Today, at least half the patients we seen are born without a two leaflet valve and have accelerated calcification of the valve. These patients present in their 50s or 60s. Aortic Valve Disease can occur in a normal trileaflet valve and occurs most commonly after age 70.
The natural history of untreated aortic stenosis results in angina, syncope or dyspnea (shortness of breath). The predicted survivals once chest pain and syncope occurs is 3 years, dyspnea is 2 years and heart failure is 1 ½ years. These outcomes have prompted aggressive surgical intervention. There is no agreed upon medical therapy for aortic stenosis.
Many patients with significant aortic stenosis will not have many clinical symptoms. They may be so subtle as to be mild shortness of breath or the patient may fatigue easily. These patients usually present in their 50’s or 60’s.Onset of severe shortness of breath in a previously asymptomatic patient happens in a very late stage of the disease. If your physician is following aortic stenosis, a surgical consultation is recommended before severe clinical symptoms occur. This improves survival with intervention and allows the thickened heart to retain a more normal condition.
The conventional treatment for aortic stenosis is still valve replacement. A cardiac angiogram is required prior to surgery to further confirm the stenotic condition and to evaluate coronary artery disease. Aortic stenosis can also be detected by echocardiography. The valve can be replaced with with a mechanical valve (metal requiring blood thinners) or tissue valve. The longevity of animal tissue valves (bioprothesis) now approaches 15-18 years. You and your surgeon will discuss merits of each valve.
Balloon angioplasty of the valve to break up the stenosis has been tried in the past without good long term success.
Catheter based valves are emerging as potential therapies in the future. Valves companies are engaged in research to look at the effectiveness and medium term success of these valves. Obviously this therapy is restricted to very high risk mortality patients (>10% predicted mortalities) and is undergoing closely scrutinized research to ascertain its place in aortic stenosis treatment. Your physician should be prepared to discuss the various options and what best fits your needs.
Degeneration in the integrity of the leaflets or annulus of the aortic valve can result in aortic insufficiency. Remember all four valves are meant to be one-way paths for the flow of blood through the heart. Tri leaflet valves can result in abnormal leaking due to weakening of the tissue. More commonly the annulus of the valve dilates so that the leaflets no longer close together.
Unlike stenosis, regurgitation causes volumes overload of the ventricle resulting in an enlarged poorly contracting ventricle. The patient can become immediately symptomatic with shortness of breath if this occurs. The condition can quickly result in heart failure and become a medical emergency.
When the more common chronic form occurs, the ventricle has a chance to adapt and dilate more slowly. This patient though somewhat short of breath can adapt until the ventricle fails. This valve problem is best diagnosed by clinical exam and an echocardiogram. Most patients will also require a cardiac catheterization.
The standard therapy is valve replacement. Replacement of a previous bioprosthesis by a catheter -based valve is one of the more exciting potential therapies down the line.
Percutaneous Value Implant in the Aortic Position
Much interest has been generated in the research and development of the transcatheter aortic valve implantation. Three vendors – Carpentier Edwards, Medtronic and St. Jude – have valves at various stages of development. The only patients considered as candidates are patients not good surgical risks and with expected operative mortalities of greater than 10 percent. Patients with a bicuspid valve because of extensive calcification are not candidates for this procedure.
With this technology still in its infancy, the Heart Valve Institute of St. Mary Medical Center currently offers screening for patients who might be appropriate for these new treatments. We will partner with another provider to offer our patients access to these treatment options.