Aortic stenosis: symptoms, monitoring and when to operate

The aortic narrowing, or aortic stenosis, is the commonest valve disease after sixty-five. What makes it disconcerting is that it progresses for years without showing anything, then the outlook shifts sharply the day the first symptoms arrive. Which is why the question is not only Do we have to operate?, but when.

The aortic valve in two sentences

The aortic valve is the heart's outlet door. With every beat it opens to let blood through into the aorta, then closes to stop it coming back. When it thickens and calcifies, that door no longer opens fully, and the heart has to push harder and harder to move the same amount of blood.

Why the valve shrinks

• Wear and calcification, by far the commonest cause, tied to age and to cardiovascular risk factors.
• Bicuspidia, a condition present from birth where the valve has only two leaflets instead of three. It often shows up earlier, around fifty or sixty, and sometimes goes with widening of theaorta.
• The sequelae of acute joint rheumatism, a late consequence of streptococcal throat infections poorly treated in childhood. This cause is still with us in Morocco when it has all but vanished in Europe, and it affects younger patients.

The three symptoms that change everything

Three manifestations mark the turning point of the disease:

• Bleeding to effort, then to increasingly modest efforts;
• Pain in the chest to the effort, to the type of tightening;
• Unease or loss of consciousness, often at the effort.

The trap is that these signs are readily put down to age or being out of shape. Yet their arrival marks the shift from a disease you watch to a disease you have to treat. That is the most important message of this article: aortic narrowing that has become symptomatic should be taken care of without delay.

How we measure it

The echocardiogram is the central test. It measures how fast blood moves through the valve, the pressure difference either side of it, and how much opening is left. Those numbers grade the severity.

A CT scan, a supervised exercise test or a coronary angiogram sometimes round out the work-up before the decision.

When do we operate?

Two situations lead to a valve replacement:

• narrowing tight and symptomatic, whatever the age ;
• narrowing tight without symptom, but with objective signs that the heart is struggling: a fall in contraction strength, measurements worsening quickly, or symptoms brought out by an exercise test.

Conversely, a moderate, well-tolerated narrowing is not operated on. It is monitored, and that monitoring has value: it is what allows the operation to happen at the right moment rather than too late.

Replace valve: options

Surgical replacement

The diseased valve is removed and replaced with a prosthetic one. The operation is done through a conventional sternotomy or, in some cases, through a Minimally invasive route which reduces the size of the scar and the recovery time.

TAVI

The new valve is deployed inside the old one, by way of the arteries, without opening the chest. This technique was reserved at first for frail patients, then widened. It is discussed as a team, on age, anatomy and whatever else may need doing at the same time.

Mechanical or biological

This is a choice to be discussed, not imposed. Your way of life, whether you can have regular blood tests, and any plan for a pregnancy weigh as heavily as your age.

After the intervention

The recovery follows a logic similar to that described in our guide to recovery after a bypass : getting up early, rehabilitation built up gradually, keeping an eye on the scar, back to your activities somewhere between six and twelve weeks. Follow-up includes a baseline echocardiogram and then regular checks, for life.

Did an ultrasound show a narrowing of your aortic valve? Dr Tber's practice in Tangier goes through your measurements, tells you exactly where you stand and whether the moment to operate has come. Book an appointment.

Frequently asked questions