STATE-OF-THE-ART PAPER
Valvular Aortic Stenosis
Disease Severity and Timing of Intervention
Catherine M. Otto, MD, FACC*
Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington
Manuscript received November 4, 2005;
revised manuscript received December 14, 2005,
accepted January 2, 2006.
* Reprint requests and correspondence: Dr. Catherine M. Otto, Division of Cardiology, Box 356422, University of Washington, Seattle, Washington 98195 (Email: cmotto{at}u.washington.edu).
Standard echocardiographic evaluation of aortic stenosis (AS) severity includes measurement of aortic velocity, mean transaortic pressure gradient, and continuity equation valve area. Although these measures are adequate for decision making in most patients, there is no single value that defines severe stenosis. Aortic stenosis affects not just the valve, but the entire vascular system, including the left ventricle (LV) and systemic vasculature. More sophisticated measures of disease severity might explain the apparent overlap in hemodynamic severity between symptomatic and asymptomatic patients and might better predict the optimal timing of valve replacement. There have been several approaches to evaluation of stenosis severity based on valve hemodynamics, the ventricular response to increased afterload, ventricular-vascular coupling, or the systemic functional consequences of valve obstruction, such as exercise testing and serum brain natriuretic peptide levels. Aortic valve replacement is indicated when symptoms due to severe AS are present. In most asymptomatic patients, the risk of surgery is greater than the risk of watchful waiting so that management includes patient education, periodic echocardiography, and cardiac risk factor modification. Many adults with AS have comorbid conditions that affect both the diagnosis and management of the valve disease, including aortic regurgitation, aortic root dilation, hypertension, coronary artery disease, LV dysfunction, and atrial fibrillation. Comorbid conditions should be evaluated and treated based on established guidelines, although awareness of the potential effects of therapy in the presence of valve obstruction is needed.
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Abbreviations and Acronyms
| | AR = aortic regurgitation | | AS = aortic stenosis | | AVA = aortic valve area | | AVR = aortic valve replacement | | CSA = cross-sectional area | | LV = left ventricle/ventricular | | LVOT = left ventricular outflow tract | | VTI = velocity-time integral | | Zva = valvulo-ventricular impedance |  P = pressure gradient |
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