Aortic Valve Stenosis

Overview

What is the aortic valve? What is aortic valve stenosis?

The heart has four chambers . In the lower left chamber (left ventricle), the aortic valve works like a one-way gate. When the heart pumps, the aortic valve opens to let oxygen-rich blood flow from the left ventricle into a large blood vessel called the aorta . Blood then flows through the aorta to the rest of the body.

Aortic valve stenosis means that this valve has narrowed, and it can't open all the way. The heart has to work harder to pump blood through the smaller opening. The heart can do this for many years, but over time it gets worn out. It can no longer send out as much blood as your body needs. If you don't get treatment, heart failure may develop.

What causes aortic valve stenosis?

Problems that can cause aortic valve stenosis include:

• Calcium buildup on the aortic valve. As you age, calcium can build up on the valve, making it hard and thick. This buildup happens over time, so symptoms usually don't appear until after age 65. Many of the same things that increase your risk for hardening of the arteries ( atherosclerosis ) make you more likely to have aortic valve stenosis. They include smoking, being male, or having high cholesterol , high blood pressure , or diabetes .
• A heart defect you were born with (congenital). Some babies are born with an aortic valve that has only two flaps instead of the normal three. This is called a bicuspid valve, and it makes a smaller opening for blood to flow through. In this case, symptoms usually start around age 40.
• Rheumatic fever or endocarditis . These infections can damage the valve.

What are the symptoms?

Aortic valve stenosis is a slow process. For many years, even decades, you will not feel any symptoms. But at some point, the valve will likely become so narrow (often one-fourth of its normal size) that you start having problems.

As aortic valve stenosis gets worse, you may have symptoms such as:

• Chest pain ( angina ). You may have a heavy, tight feeling in your chest. Chest pain is often brought on by exercise, when the heart has to work harder.
• Feeling dizzy or faint, often after you have been active.
• Feeling tired and being short of breath when you are active.
• A fast, slow, or uneven heartbeat ( arrhythmia ).
• A feeling that your heart is pounding, racing, or beating unevenly ( palpitations ).

If you start to notice any of these symptoms, let your doctor know right away. If you have symptoms, you need treatment. By the time you have symptoms, your condition probably is serious. If you have symptoms, you also have a high risk of sudden death. ¹

How is aortic valve stenosis diagnosed?

Most people find out they have it when their doctor hears a heart murmur during a regular physical exam. To be sure of the diagnosis, your doctor may want you to have an echocardiogram , which can show moving pictures of your heart. You may have other tests to help your doctor judge how well your heart is working.

How is it treated?

If symptoms develop, you will probably need surgery right away. Surgery to replace the aortic valve is the best treatment for most people. View a slideshow on aortic valve replacement surgery . Young people or people who cannot have open-heart surgery may have another procedure called balloon valvuloplasty to enlarge the valve opening.

If you do not have surgery after you start having symptoms, you may die suddenly or develop heart failure. Most people who have symptoms of severe aortic valve stenosis die within 2 to 5 years if they do not have valve replacement surgery. ² Surgery can help you have a more normal life span.

If you don't have symptoms, your doctor will see you regularly to check your heart. You probably will not have surgery. Until you have symptoms, surgery is likely to be more risky than the disease. ³

Medicines do not cure the disease, but they can treat some problems that aortic valve stenosis can cause. You might need to take medicines that help control irregular heart rhythms or blood thinners ( anticoagulants ) to prevent blood clots.

Health Tools 

Health Tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	Aortic valve stenosis: Should I choose a mechanical valve or a tissue valve to replace my aortic valve?
	Aortic valve stenosis: Should I have surgery?

Frequently Asked Questions

Cause

Most people who have aortic valve stenosis are born with a normal, healthy aortic valve but develop aortic stenosis late in life. Aging and calcium buildup cause the leaflets of the valve to thicken and harden, preventing the valve from opening properly. Typically, stenosis develops slowly over many years.

Aortic valve stenosis also occurs in people who are born with a valve that has two flaps instead of three ( congenital bicuspid valve ) or in people who have had rheumatic fever . In either of these cases, the leaflets do not open as widely as they should. This creates a smaller opening and makes it much harder for blood to flow from the left ventricle into the aorta .

Symptoms

You probably will not have any symptoms if you have mild or moderate aortic valve stenosis , because your heart can make up for the stenosis. You may begin to notice symptoms if the pressure buildup in the heart becomes severe or if blood flow to the heart and the rest of the body is reduced. Symptoms may include:

• Chest pain ( angina ) or discomfort, often described as a heavy, tight feeling in your chest. You may also have a burning, choking, or constricting feeling that may spread to your arms, shoulders, or neck. You may have chest pain when you exercise or do something strenuous because your heart has to work harder.
• Dizziness, fainting, or loss of consciousness, often after periods of activity.
• Signs of heart failure , such as fatigue and shortness of breath with activity.
• Rapid or irregular heartbeat ( arrhythmia ).
• Palpitations (an uncomfortable feeling that your heart is beating rapidly or irregularly).

What Increases Your Risk

Certain medical problems or conditions make it more likely that you will develop aortic valve stenosis :

• Calcium buildup. Aging can cause calcium buildup around the aortic valve, which can make the normally thin and flexible valve flaps thick and stiff. This is also called calcific aortic valve stenosis. It is unclear why some people develop calcium buildup while others don't. This calcium buildup may be related to the same process that causes atherosclerosis, or hardening of the arteries. In fact, many of the things that increase the risk of atherosclerosis and heart disease are the same for aortic valve stenosis. They include smoking, high cholesterol , high blood pressure , diabetes , and being male. ^{4, 5}
• Birth defect. Sometimes a person is born with a bicuspid aortic valve that has two flaps instead of the normal three. Over time, the valve becomes damaged and calcium builds up. As the valve narrows, less blood can flow through it.
• Infection. Rheumatic fever can cause scar tissue to build up at the edges of the valve. The scar tissue binds the corners of the flaps together, limiting their ability to open fully. The most common cause of rheumatic fever is strep throat that has not been treated. Because antibiotics have been widely used to treat strep throat, rheumatic fever has been uncommon in the United States since the 1970s.
• Artificial valve. Aortic valve disease also may develop in an artificial aortic valve that is made from human or animal tissue.

Other things that increase the risk for aortic valve stenosis include:

• Being male. Men are at higher risk than women.
• Atherosclerosis . In some studies, the buildup of plaque in the arteries has been associated with aortic valve stenosis.
• Kidney failure.
• Smoking.

When to Call a Doctor

If you experience any of the symptoms of aortic valve stenosis , such as chest pain, fainting, or shortness of breath, call your doctor immediately. Aortic valve stenosis generally does not cause symptoms until the condition has become quite severe. The longer you try to live with symptoms of stenosis and its complications without seeking medical attention, the more you risk getting heart failure .

The table below explains why these symptoms occur.

Watchful waiting

Watchful waiting is a "wait-and-see" approach that is not appropriate if you have chest pain, shortness of breath, palpitations, or fainting. Contact your doctor immediately.

If you have been diagnosed with aortic valve stenosis but you do not have symptoms, you and your doctor should discuss a plan to check your heart regularly. You may have mild stenosis and have no symptoms for many years. You may never develop symptoms. There is some debate about whether people who don't have symptoms should have valve replacement surgery.

But even if you don't have symptoms, if tests show your left ventricle is not working right or you have an exercise stress test that is abnormal, your doctor may recommend valve replacement.

Who to see

Your family doctor may diagnose aortic valve stenosis during a routine checkup. Other health professionals who also may discover aortic valve stenosis during a physical exam include:

• Nurse practitioners .
• Internists .
• Physician assistants .
• Cardiologists .

If you have any of the symptoms of aortic valve stenosis or heart failure but have not been diagnosed with aortic valve stenosis, you do not necessarily need to see a heart specialist (cardiologist) immediately. Your family doctor can evaluate your symptoms. If your doctor thinks that you do have stenosis, the doctor will likely have you take an echocardiogram .

With mild cases of stenosis, only regular monitoring may be necessary, in which case you may be able to continue seeing your family doctor. If you have (or develop) more severe stenosis, your doctor can help you to decide when to involve a cardiologist in your treatment.

Considerations for children

If a pediatrician detects a heart murmur in a child or teen, the murmur may be a sign of a heart defect that has been present since birth, such as a bicuspid aortic valve (which has two valve flaps instead of three). In most cases, a pediatrician will recommend an echocardiogram, which can identify a defect. A pediatrician may refer your child to a pediatric cardiologist for further evaluation and treatment.

Exams and Tests

A physical exam and review of your medical history are important first steps in diagnosing aortic valve stenosis . If you have stenosis but no symptoms, your doctor will likely find the condition during a routine exam or a checkup for another health problem. A distinctive heart murmur is usually the first clue that leads a doctor to suspect aortic valve stenosis.

During the physical exam, the doctor will:

• Take your blood pressure. Low blood pressure may mean that not enough blood is getting through the narrowed aortic valve.
• Check your pulse. A weak pulse may mean there is narrowing of the heart valve.
• Listen to your heart and lungs for abnormal sounds. A soft whooshing or humming sound (murmur) heard through a stethoscope is an important finding that often indicates heart valve disease. Abnormal sounds in the lungs can indicate fluid buildup in the lungs that is caused by heart valve disease.
• Look at your legs and feet. Swelling in the legs and feet may be a sign of heart failure .

After the exam

Your doctor may want to do an echocardiogram to confirm that your symptoms and the results of your exam are caused by aortic valve stenosis. The echocardiogram will also tell your doctor:

• How severe the stenosis is.
• How wide your aortic valve can open.
• The difference in pressure between the heart and the aorta, resulting from blood being forced through the narrowed valve.
• The size of your left ventricle.
• How well your left ventricle is working.
• Whether there are problems with other valves.

Tests for aortic valve stenosis

• Echocardiogram (echo). If you have aortic valve stenosis, an echocardiogram may show thickened aortic valve leaflets that aren't moving normally.
• Stress echocardiogram. A stress echocardiogram can show how severe your aortic valve stenosis is and how it affects how much you can exercise.
• Electrocardiogram (EKG or ECG). An electrocardiogram may show abnormalities in heart rhythm or lower left heart chamber (ventricle) thickness.
• Chest X-ray. A chest X-ray may show calcium buildup in the valve, an enlarged left ventricle, or fluid buildup if you have developed heart failure. In some cases, the aorta may be enlarged just beyond the aortic valve.
• Brain natriuretic peptide (BNP) test. A BNP test may help show how well your heart is working and if you have heart failure.
• Coronary angiogram/catheterization. Cardiac catheterization is the most accurate way to see how narrow the valve is.

Treatment Overview

Treatment for aortic valve stenosis usually depends on whether you have symptoms. If you have symptoms, surgery to replace the aortic valve is usually required. View a slideshow on aortic valve replacement surgery .

In most cases, if you have symptoms, the risk of not treating aortic valve stenosis is higher than the risk of having surgery. Most people who have symptoms of severe aortic valve stenosis die within 2 to 5 years if they do not have valve replacement surgery. ²

Doctors may prefer balloon valvuloplasty for teens, young adults in their 20s, or people for whom valve surgery is too great a risk. This treatment involves inserting a tiny balloon into the aortic valve and expanding it to open the valve. While this is less risky than valve surgery, it is usually only a temporary treatment in anyone other than young people.

For most people, valve replacement is the only effective treatment. You and your doctor need to decide whether to replace the aortic valve at the time you are diagnosed or delay until later. Depending on the results of your tests, you may also require additional heart surgery during your valve replacement surgery, such as coronary artery bypass grafting . For more information about valve replacement surgery, see:

Should I have surgery to replace my aortic valve?

You may need medicine to prevent or treat a heart infection or heart failure . If you have surgery to receive an artificial valve, you also may have to take blood thinners ( anticoagulants ) to prevent blood clots from forming. For more information, see the Medications section of this topic.

Ongoing Concerns

Aortic valve stenosis can be an easy condition to miss. In its mild form, you may not even realize that you have it, because it has not yet begun to cause symptoms. The condition may not be found unless you have tests for another possible heart condition.

If you do not yet have symptoms, you may go a long time without having them. This phase can last for 10 years or more. During this phase, you may have an echocardiogram every 6 months to every few years to check the condition of your valve.

If you have an artificial valve , you may need to take antibiotics before you have certain dental or surgical procedures. The antibiotics help prevent an infection in your heart called endocarditis .

If you have aortic valve stenosis, you are at risk of getting iron deficiency anemia due to a condition called angiodysplasia. With angiodysplasia, you have gastrointestinal bleeding and symptoms of anemia. Be aware that the symptoms of anemia are similar to some of the symptoms of aortic valve stenosis.

If you have aortic valve stenosis, you cannot prevent it from getting worse or causing symptoms, including chest pain ( angina ), fainting, and shortness of breath.

After symptoms of stenosis develop, you must decide with your doctor whether to have valve replacement surgery. This surgery is the only effective treatment. Without it, heart failure will likely develop and shorten your life. ⁶ View a slideshow on aortic valve replacement surgery .

Most people who have symptoms of severe aortic valve stenosis die within 2 to 5 years if they do not have valve replacement surgery. ² With surgery, you may reach a normal life expectancy. For more information about valve replacement surgery, see:

Should I have surgery to replace my aortic valve?

Complications

As aortic valve stenosis progresses, it often causes complications that can have a serious impact on your overall health. Heart failure is the most common and potentially the most life-threatening complication. Other complications include chest pain, fainting, irregular heartbeat, and heart infection. In rare cases, aortic valve stenosis can cause sudden death before you have symptoms. Sudden death is more common in people who have bicuspid aortic valves .

Living With Aortic Valve Stenosis

How you will feel and how aortic valve stenosis will affect your life will vary greatly depending on whether you have symptoms and the treatment decisions you make.

If you have no symptoms

You may be surprised when you first learn that you have aortic valve stenosis, because you may not have symptoms. In fact, you may even have quite severe stenosis and still not feel any symptoms or show physical signs. But even if you feel fine, there are still many things you will have to keep in mind.

It is important that you watch closely for any signs of chest pain, lightheadedness, fainting, or shortness of breath. See your doctor promptly if you develop these symptoms or others that concern you. You are more likely to have symptoms while exercising or doing other strenuous activity than at other times. Discuss with your doctor what kinds of exercise are safe for you. There is no way to predict when symptoms will develop.

You can keep your heart healthy and lower your risk of coronary artery disease with a heart-healthy diet and lifestyle such as not smoking, staying at a healthy weight, being active, and managing diabetes, high blood pressure, and high cholesterol.

You also will need to have an echocardiogram every 6 months to 1 year for severe stenosis and every 1 to 5 years for mild to moderate stenosis.

If you have severe stenosis, avoid strenuous physical activity. In rare cases, sudden death can occur if enough blood cannot get to your heart muscle during strenuous physical activity.

If you have symptoms

After symptoms of stenosis appear, you'll need to decide whether to have valve replacement. Because it is the only effective long-term treatment, valve replacement surgery is recommended unless you are in such poor health the surgery would be too risky or you have other reasons not to have it. For more information about valve replacement surgery, see:

Should I have surgery to replace my aortic valve?

If you do not have surgery, you will likely develop severe heart failure , which will shorten your life. But you can make lifestyle changes to manage heart failure, including:

• Eating a low-sodium diet and being careful about how much fluid you drink.
• Taking medications for heart failure. For more information, see the topic Heart Failure.
• Being active with walking or other mild exercise. You should discuss with your doctor what type of exercise is safe for you.
• Quitting smoking.
• Limiting activities that may strain you, such as travel and sex.

If you choose to have surgery, you should know that it will likely involve a long recovery. On average, people who have valve replacement take 3 to 6 weeks off from work. In some cases, full recovery may take several months.

After you recover from surgery, you will still need to take antibiotics when necessary to guard against an infection in your heart ( endocarditis ). You may also need to take a blood thinner ( anticoagulant ) to prevent blood clots, depending on the type of valve you have. If you have a mechanical valve, you will have to take blood thinners as long as you have the valve.

If you have an artificial valve , you may need to take antibiotics before you have certain dental or surgical procedures. The antibiotics help prevent an infection in your heart called endocarditis .

End-of-life issues

Most people who have symptoms of severe aortic valve stenosis but do not have valve replacement surgery die within 2 to 5 years. ² For this reason, it is important to consider end-of-life issues.

If you choose not to have surgery, your doctor will prescribe medications to make you comfortable. As you get sicker, you may be unable to make decisions about your medical care. You may want to consider the type of care you wish to receive in case you are unable to make your wishes known. For more information, see the topic Care at the End of Life.

Medications

You may need to take medicines to prevent and treat complications of aortic valve stenosis .

If you have valve replacement surgery with a man-made (mechanical) valve, you also will need to take blood-thinning ( anticoagulant ) medication (such as heparin or warfarin [for example, Coumadin]) for the rest of your life. These medicines prevent blood clots from forming around the valve.

Some doctors also recommend taking low doses of aspirin in addition to warfarin. If you receive a biological (tissue) replacement valve instead of a mechanical valve, you may need to take anticoagulants for only a few months. After that time, you may be able to take aspirin alone.

If you have an artificial valve , you may need to take antibiotics before you have certain dental or surgical procedures. The antibiotics help prevent an infection in your heart called endocarditis .

If an infection develops in your heart, your doctor will prescribe high-dose antibiotics for a much longer period of time than if you were trying to prevent an infection.

If aortic valve stenosis leads to irregular heartbeats ( arrhythmias ), you may need to take medicines that help control irregular heart rhythms until surgery can be done.

If you develop heart failure , you may be able to take medicines such as diuretics, digoxin, vasodilators, or beta-blockers to help your heart pump blood more effectively. For more information, see the topic Heart Failure.

Surgery

Your doctor will likely recommend valve replacement surgery if you have symptoms of aortic valve stenosis , unless you have other conditions that make surgery too risky. Symptoms such as chest pain, fainting, and shortness of breath indicate that you have severe narrowing of your aortic valve. If you do not have surgery to replace the valve, you will have a much shorter life span. In rare cases, you could die suddenly.

Most of the time, valve replacement surgery is a straightforward procedure with a high rate of success and a low risk of complications.

Aortic valve replacement

Aortic valve replacement is either an open-heart procedure or a minimally invasive procedure. In an aortic valve replacement surgery, the damaged valve is removed and replaced with an artificial valve (mechanical or tissue). View a slideshow on aortic valve replacement surgery . Several different types of replacement valves are available. For more information about types of replacement valves, see:

Should I replace my aortic valve with a mechanical or tissue valve?

In rare cases, the aortic valve may be replaced with one of your other heart valves. Usually the pulmonic valve is used. This valve is located between the lower right heart chamber and the opening to the artery that goes to the lungs. An artificial valve is used to replace the pulmonic valve. This type of valve surgery may be used in people younger than 25 who stand to benefit the most from this difficult surgery. The pulmonic valve is more durable, grows with the person, and has a lower risk of infection.

Valve replacement surgery is high-risk for people who either have a failing left ventricle, coronary artery disease , or have had a heart attack .

Medical experts debate whether valve replacement surgery should be done for aortic valve stenosis that is not causing symptoms. Although no current research supports this approach, some doctors believe that repair or replacement surgery should be done as soon as severe stenosis is found because of the small risk of sudden death.

Other doctors believe surgery isn't necessary until symptoms develop. These doctors believe that the risk of sudden death is less than the risks of surgery. If surgery is delayed, regular follow-up exams (including echocardiograms ) are needed to monitor changes in the valve structure and heart function. These tests may indicate when surgery is needed.

In most cases, if you have symptoms, the risk of not replacing the valve is higher than the risk of having surgery. The majority of people who have symptoms of severe aortic valve stenosis die within 2 to 5 years if they do not have valve replacement surgery. ²

The risk of surgery is higher than average for people who have severe aortic valve stenosis, failure of the left ventricle, and a low ejection fraction . But one study has found that even people in this higher-risk group benefit from valve replacement. Valve replacement surgery is also high-risk for people who have coronary artery disease or have had a heart attack .

Before having valve replacement surgery, your doctor may suggest you have a coronary angiogram/catheterization test. This test can show if you have blockages in your coronary arteries (as part of coronary artery disease). If you have serious blockages, your doctor may want to do a coronary artery bypass surgery at the same time as the valve replacement surgery.

Other aortic valve surgery

Balloon valvuloplasty may be an option for some younger people who have aortic valve stenosis. Although the heart valve is not replaced, the narrowed opening is made larger during this procedure.

What to think about

Should I have surgery to replace my aortic valve?

Should I replace my aortic valve with a mechanical or tissue valve?

Other Places To Get Help

Organizations

Related Information

• Chest Problems
• Coronary Artery Disease
• Endocarditis
• Heart Failure

References

Citations

1. Bonow RO, et al. (2006) ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease). Circulation, 114(5): e84–e231.
2. Stewart WJ, Carabello BA (2007). Aortic valve disease. In EJ Topol et al., eds., Textbook of Cardiovascular Medicine, 3rd ed., pp. 366–388. Philadelphia: Lippincott Williams and Wilkins.
3. Aikawa K, Otto C (2001). Timing of surgery in aortic stenosis. Progress in Cardiovascular Diseases, 43(6): 477–493.
4. Rajamannan NM, et al. (2003). Calcific aortic stenosis: From the bench to the bedside—Emerging clinical and cellular concepts. Heart, 89: 801–805.
5. Pohle K, et al., (2004). Association of cardiovascular risk factors to aortic valve calcification as quantified by electron beam computed tomography. Mayo Clinic Proceedings, 79 (10): 1242–1246.
6. Carabello BA (2002). Aortic stenosis. New England Journal of Medicine, 346(9): 677–681.

Other Works Consulted

• Carabello BA (2002). Evaluation and management of patients with aortic stenosis. Circulation, 105: 1746–1750.
• Nishimura RA, et al. (2008). ACC/AHA 2008 guideline update on valvular heart disease: Focused update on infective endocarditis: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation, 118(8): 887–896.
• Rahimtoola SH (2004). Aortic valve disease. In V Fuster et al., eds., Hurst's The Heart, 11th ed., vol. 2, pp. 1643–1667. New York: McGraw-Hill.

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