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Aortic Valve Stenosis
Aortic stenosis occurs when the aortic valve becomes narrow and does not allow
enough blood to flow through it to the body. The aortic valve is located between the left
ventricle of the heart (the pumping chamber) and the aorta, the blood vessel that carries
oxygen-rich blood from the heart to the body.
When an aortic valve is narrowed, it limits the flow of blood from the heart’s pumping
chamber into the aorta. Blood that cannot pass through the valve backs up in the heart.
This backup places pressure on the heart’s chambers and the blood vessels that bring
blood from the lungs to the heart. Over time, the pressure may contribute to enlarged
heart chambers and congestion in the lungs, which leads to congestive heart failure.
A narrowed aortic valve can cause tiredness and shortness of breath, especially when
climbing stairs, exercising or doing other activities.
Treatments for Aortic Valve Stenosis
Depending on your condition and symptoms, your doctor may recommend the following:
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Medications, and salt restricted diet
Surgical treatment: aortic valve replacement
Aortic valvuloplasty
Medications
If tests show minor or moderate narrowing of the aortic valve, your cardiologist may
recommend monitoring your condition during regular checkups. Monitoring may be done
with echocardiography (ultrasound). Some people never need any treatment because
they never develop severe aortic stenosis.
If you experience symptoms, your doctor may prescribe medications and dietary
restrictions to provide relief. These medications and restrictions may include the
following:
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Diuretics, drugs that help reduce fluid accumulation in your body by increasing
fluid loss through urination;
Blood thinners, or anticoagulants, which help prevent blood clots from forming;
Drugs to control an irregular heartbeat, such as the too-fast heart rhythm of atrial
fibrillation (AF).
Salt (sodium) Restriction: Foods high in salt can cause fluid retention and worsen
symptoms related to heart valve disease. A low salt diet of only 2-3 grams of
sodium per day is recommended, which means that salt should not be added to
food, and high sodium foods like deli meats, nuts, canned soup, and fast food
should be avoided.
Even if you are on medications, if you notice an increase in fatigue or shortness of
breath, let your doctor know immediately.
Surgical Treatments
Your cardiologist may recommend surgery to repair or replace a narrowed aortic valve.
Valve replacement is by far the most frequent treatment.
What to expect. For surgery, you will receive a general anesthetic. Your doctor will
make an incision the length of your breastbone (the flat bone in the center of your chest)
to expose your heart. You will be connected to a heart-lung machine, which will take
over your breathing and blood circulation during the surgery. The surgeon will stop your
heart, make an incision to expose the valve and then replace the valve.
Valve repair. Surgery to repair, rather than replace, the aortic valve may be an option in
special circumstances:
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Infants in whom the valve’s leaflets have grown together;
Adults with scarred or fused leaflets from rheumatic fever;
Patients with obstructions on or near the valve
Improved blood flow through the valve can be accomplished by surgically separating the
valve’s leaflets, or removing tissues that obstruct the valve.
Valve replacement. If your valve cannot be repaired and it must be replaced, your
surgeon will implant an artificial, or prosthetic, valve. Artificial valves are either
mechanical or tissue (bioprosthetic).
Mechanical valves
 Mechanical valves are devices made of advanced materials, such as pyrolytic
carbon and titanium. They offer life-long durability. The main risk with mechanical
valves is blood clot formation (thromboembolism).
 A secondary risk is associated with the blood-thinning medications you will need
to take for the rest of your life after receiving a mechanical valve. These
anticoagulant medications are critical because they help reduce the likelihood of
blood clots. Blood clots are dangerous: If they break loose in the bloodstream,
they can clog vessels and lead to stroke or heart attack.
 Taking blood-thinning medications increases the risk of bleeding. If the
anticoagulant drugs make the blood too “thin,” you can experience excessive
bleeding, even with minor cuts. If the blood is too “thick,” clots can form on the
valve. Once they have formed, they can break away, lodge in a blood vessel and
cut off blood flow to the heart or brain. This can result in heart attack or stroke.
 Careful monitoring to ensure the correct levels of anticoagulation medications is
critical. It may require a monthly visit to the doctor’s office. Or, new home
monitoring units make it possible to regulate your blood-thinning medications
without going in for a regular test.
Tissue valve
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Tissue valves are made of valve tissue taken from a cow (bovine), pig (porcine)
or human (homograft). Because they do not encourage blood clot formation,
patients who receive tissue valves for aortic stenosis do not need to take bloodthinning medicines beyond the first few months after the surgery.
However, tissue valves have not historically been as long lasting as mechanical
valves. A tissue valve can wear out over a period of 10 to 15 or more years. If it
deteriorates significantly, it must be replaced. Replacement, of course, requires
repeat surgery, with its associated risks. Because of durability concerns, tissue
valves are implanted primarily in older patients. However, tissues valves have
improved steadily and are being used more and more frequently.
Risks of heart valve surgery
 The overall mortality risk (risk of death) for heart valve surgery is about 5 percent
(5 out of every 100 patients).
 Irregular heartbeat—or arrhythmia—may occur. You may need to take
anticoagulant (blood thinning) medications to lower the risk of blood clots, which
may form in the heart due to irregular heartbeat.
 Infection. After valve surgery, you may be prone to endocarditis, an infection or
inflammation of the heart’s inner lining. It occurs when bacteria enter the
bloodstream and infect damaged heart tissue. Antibiotics are given before noncardiac surgery and dental work to prevent this complication. People who have
abnormal or damaged heart valves or have received an artificial heart valve are
more vulnerable to the infection.
 Risks are associated with being put to sleep with general anesthesia.
 Risks, such as bleeding, are associated with surgery.
 A valve repair may not last—or it may not work as planned. A tissue valve may
need to be replaced if it wears out. In either case, the operation may need to be
repeated.
After valve surgery. Your recovery in the hospital may last from six to 10 days,
depending on your condition. You may spend the first days after surgery in an intensive
care unit (ICU) where your heart will be closely monitored.
While in the ICU, you may have a number of tubes in your body to help recovery,
including a tube to help you breathe, a tube to drain fluids from the stomach while you
are not eating, tubes to drain fluid from your chest, a small tube to empty your bladder
and a line into your arm to measure blood pressure. These will be removed when you
are moved from the ICU to another care unit.
You will receive therapy to prevent complications such as pneumonia, collapsed lung or
infection. A nurse or therapist may lead you in deep breathing exercises and coughing
and encourage you to move your legs to lower the chance of blood clot formation. Your
therapy may also include gentle patting on the back to loosen fluids in the lungs.
Physical therapy will also be part of the recovery process. In the hospital, you will be
encouraged to walk around and shown how to move your arms without hurting your
breastbone. Pain medication will ease the discomfort of the surgical incision, and you
will learn how to do daily activities in ways that will not interfere with the healing
process.
Aortic Valvuloplasty
(Content provided courtesy of Evanston Hospital, Evanston, Illinois.)
Description:
This is a non-surgical procedure that may be used to open a narrow valve within the
heart.
Aortic stenosis:
A narrowing (or stenosis) of one of the four valves within the heart. Valves normally
open and close with each heart beat to allow blood to continue in a forward motion
through the heart. When a valve is narrow, it does not open as much as it should, so the
pressure of the blood backs up within the heart and causes the blood vessels in the
lungs to have too much pressure. Think of a garden hose that is kinked and resulting
pressure that builds up at the wall faucet. This can cause a person to be short of breath,
especially with exertion such as climbing stairs or exercising, or develop congestive
heart failure, which is a fluid buildup in the heart and lungs.
What to expect
The procedure can be performed on the same day of admission, and people usually
stay 1 or 2 nights in the hospital. People that take the blood thinner Coumadin, must be
switched to the short acting blood thinner Lovenox (which is injected like insulin) or
admitted to the hospital 2 days in advance for intravenous blood thinner therapy with
Heparin.
A special echocardiogram (ultrasound of the heart) called a TEE may be performed the
morning of, or in the weeks prior to the procedure. TEE is a trans esophageal echo in
which the person is put to sleep with IV medication and a small ultrasound probe is
passed down the esophagus (the swallowing tube). The heart structures are then
viewed through the wall of the esophagus. This is not a painful procedure because the
individual is asleep during the test. It is a very important test because it detects any
blood clots that are in the heart. If a blood clot is found, the valvuloplasty usually will not
be performed because the risk of causing a stroke would be too high.
The valvuloplasty procedure is done in the cardiac catheterization lab using X-ray and a
dye that is injected into the blood stream. Local anesthetic (numbing medicine) is given
in the crease of both legs before the tubes (or sheaths) are placed into the blood
vessels in that area. Once the numbing medicine has taken effect, there should only be
a sensation of pressure, while the tubes are placed. Intravenous medicine for relaxation
is usually given, so that a person may doze off to sleep during the procedure. People
are not put into a deep sleep, however, so that they can talk to the doctor during the
procedure.
A soft plastic tube is passed through the blood stream up to the heart where pressure
measurements are taken, and the arteries of the heart are visualized using X-ray and
intravenous dye. This does not cause pain because there are no nerves inside those
blood vessels. Once the measurements are taken the doctor can reach the aortic valve
in one of two ways. Sometimes a tiny needle is used within the heart to cross from the
right side into the left side to approach the aortic valve, in other cases it is approached
directly from the aorta (i.e., the large artery that runs through the center of the body).
The valvuloplasty balloon is passed through the wall and positioned across the narrow
aortic valve. The balloon is quickly inflated and deflated within the valve to stretch the
valve open. This may be performed two or three times. During balloon inflation, a
person may feel warmth or flushing in the face or chest, pressure in the chest, or mild
chest discomfort. This usually passes in 5 to 10 seconds. When the procedure is
finished all tubes and the balloon are removed from the blood stream and pressure is
applied to the site in the crease of the leg to prevent bleeding. Bed rest for a few hours
after the procedure is important to prevent bleeding.
Risks associated with the procedure:
The doctor and nurse discuss risks in detail with all patients. Those risks include:
 There is a small risk of bleeding from the site where the tubes enter the skin. The
sites may be closed with a “stitch” or a “glue plug” or may be held by manual
pressure after tubes are removed. Bed-rest is necessary for a few hours after the
procedure to reduce the chance of bleeding. In a rare situation a blood
transfusion or surgery to repair a damaged blood vessel in the leg may be
necessary.
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There is a small risk of a stroke, heart attack, allergy, or kidney problems related
to the IV dye. People may have a temporary irregular heart rhythm after the
procedure, with a 5-10% risk of needing a pacemaker. .
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There is a small chance that the balloon will not improve the opening of the
valve. In that case the doctor may discuss scheduling open-heart surgery to
replace the valve in the following weeks or months.
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There is a small chance that the balloon may damage the valve, which would
require open-heart surgery to replace the valve, possibly even that same day.
This risk of dying during the procedure is approximately 5% or 5 in 100.
What to do before the procedure:
It is important not to eat or drink anything after midnight the night before the procedure.
Medications are usually taken with sips of water during that time, but specific
instructions are given to each person beforehand. Those individuals that have an allergy
to the IV dye must tell the doctor or nurse so that medication to prevent a reaction can
be prescribed. Persons taking blood thinners will be instructed when to stop prior to the
procedure. Glasses, dentures and hearing aids are permitted during the procedure.