Valve Disease Management

Introduction to Aortic Stenosis

Patients with mild-to-moderate aortic insufficiency and moderately elevated pulmonary artery systolic pressure require close monitoring and medical therapy, with surgical intervention indicated if symptoms develop or left ventricular dysfunction progresses, as recommended by the American College of Cardiology 1, 2
Stage B progressive aortic stenosis is characterized by mild-to-moderate leaflet calcification, mild AS with aortic velocity 2.0-2.9 m/s or mean pressure gradient <20 mm Hg, and early LV diastolic dysfunction may be present, with no symptoms, as defined by the American Heart Association/American College of Cardiology (AHA/ACC) guidelines 3

Regular clinical follow-up every 6-12 months is recommended for patients with Stage B progressive aortic stenosis 4
Echocardiographic evaluation every 1-2 years is recommended to monitor progression of aortic stenosis severity, changes in LV size and function, and development of symptoms 3, 4
Parameters to monitor include aortic valve velocity and gradient, valve area, LV dimensions and wall thickness, LV systolic function, and progression of aortic valve calcification 3
Statin therapy may be considered for its potential pleiotropic effects, although evidence for slowing progression of aortic stenosis is limited, as suggested by the American Heart Association 5
Beta-blockers may be beneficial for patients with Marfan syndrome or bicuspid aortic valve with aortic root dilatation to slow aortic root dilatation 4

Intervention (surgical or transcatheter aortic valve replacement) is not indicated for patients with mild AS and no symptoms, but would be considered if symptoms develop, AS progresses to severe, LV systolic dysfunction develops, or the patient undergoes cardiac surgery for another indication, as recommended by the AHA/ACC guidelines 3, 4
Surgery should be considered in patients with development of symptoms, such as dyspnea, decreased exercise tolerance, or heart failure, as recommended by the American College of Cardiology and the American Heart Association 1, 2

Moderate aerobic exercise is generally permitted, but strenuous physical exercise, competitive, contact, and isometric sports should be avoided, particularly if there is evidence of aortic root dilatation, as recommended by the American Heart Association 4
Careful questioning about changes in exercise capacity is important to avoid overlooking symptoms, as suggested by the American Heart Association 4

The average rate of progression in moderate AS is an increase in jet velocity of 0.3 m/s per year, an increase in mean pressure gradient of 7 mmHg per year, and a decrease in valve area of 0.1 cm² per year, with marked individual variability, as reported by the European Society of Cardiology 5
Regular echocardiographic follow-up is crucial to detect rapid progression, which may warrant earlier intervention, as recommended by the AHA/ACC guidelines 3, 5