Aortic Disease

Aortic valve disease is a condition in which the valve between the main pumping chamber of your heart (left ventricle) and the main artery to your body (aorta) doesn't work properly. Aortic valve disease sometimes may be a condition present at birth (congenital heart disease), or it may result from other causes.

Types of aortic valve disease include:

  • Aortic valve stenosis. In this condition, the aortic valve opening is narrowed. This narrowing prevents the valve from opening fully, which obstructs blood flow from your heart into your aorta and the rest of your body.
  • Aortic valve regurgitation. In this condition, the aortic valve doesn't close properly, causing blood to flow backward into the left ventricle

Aortic valve stenosis

Aortic valve stenosis — or aortic stenosis — occurs when the heart's aortic valve narrows. This narrowing prevents the valve from opening fully, which obstructs blood flow from your heart into your aorta and onward to the rest of your body.

When the aortic valve is obstructed, your heart needs to work harder to pump blood to your body. Eventually, this extra work limits the amount of blood it can pump and may weaken your heart muscle.

If you have severe aortic valve stenosis, you'll usually need surgery to replace the valve. Left untreated, aortic valve stenosis can lead to serious heart problems.

To diagnose your condition, your doctor will review your medical history and symptoms and conduct a physical examination. As part of a routine physical exam, your doctor uses a stethoscope to listen to your heart. He or she is listening for, among other things, an abnormal heart sound (heart murmur).

If your doctor discovers a heart murmur, he or she will discuss it with you. Many heart conditions, including aortic valve stenosis, can produce a heart murmur. In the case of aortic valve stenosis, the heart murmur results from turbulent blood flow through the narrowed valve.

Diagnostic tests

If your doctor suspects that you or your child may have a deformed or narrowed aortic valve, you may need to undergo several tests to confirm the diagnosis and gauge the severity of the problem. You may be referred to a doctor trained in heart conditions (cardiologist) for tests such as:

  • Echocardiogram. This test uses sound waves to produce an image of your heart. This is the primary test your doctor may use to diagnose your condition if he or she suspects you have a heart valve condition. In an echocardiogram, sound waves are directed at your heart from a wandlike device (transducer) held on your chest. The sound waves bounce off your heart and are reflected back through your chest wall and processed electronically to provide video images of your heart.

An echocardiogram helps your doctor closely examine the heart and heart valves to check for any problems or abnormalities. This test helps your doctor to diagnose aortic valve stenosis, evaluate the severity of your condition and determine the most appropriate treatment for your condition. An echocardiogram will also be used to monitor your condition over time.

In some cases, your doctor may insert a tube with a transducer attached to it and guide it down your throat into your esophagus (transesophageal echocardiogram) while you are sedated. This type of echocardiogram may offer more detailed images of your heart.

  • Electrocardiogram (ECG). In this test, patches with wires (electrodes) are attached to your skin to measure the electrical impulses given off by your heart. Impulses are recorded as waves displayed on a monitor or printed on paper. An ECG can provide clues about whether the left ventricle is thickened or enlarged, a problem which can occur with aortic valve stenosis.
  • Chest X-ray. An X-ray image of your chest allows your doctor to check the size and shape of your heart to determine whether the left ventricle is enlarged — a possible indicator of aortic valve stenosis.

A chest X-ray can also reveal calcium deposits on the aortic valve. In addition, a chest X-ray helps your doctor check the condition of your lungs. Aortic valve stenosis may lead to blood and fluid backing up in your lungs, which causes congestion that may be visible on an X-ray.

  • Cardiac catheterization. Your doctor may order this procedure if noninvasive tests haven't provided enough information to firmly diagnose the type or severity of your heart condition. In this procedure, your doctor threads a thin tube (catheter) through an artery in your arm or groin and guides it to an artery in your heart.

Doctors may inject a dye through the catheter, which helps your arteries become visible on an X-ray (coronary angiogram). This test helps show any blockages in arteries to your heart that can coexist with aortic valve stenosis that may need surgical treatment along with aortic valve stenosis.

  • Exercise tests. In exercise tests, you exercise to increase your heart rate and make your heart work harder. If you have severe aortic valve stenosis but aren't experiencing symptoms, your doctor may order exercise tests to evaluate how your heart responds to exertion (exercise) and to measure your tolerance for activity.
  • Computerized tomography (CT) scan. A CT scan uses a series of X-rays to create detailed images of your heart and heart valves. Doctors may use this test to measure the size of your aorta and look at your aortic valve more closely. Sometimes doctors may inject a dye into your blood vessels to show the blood flow (CT angiography).
  • Magnetic resonance imaging (MRI). An MRI uses powerful magnets and radio waves to create detailed images of your heart and heart valves. Doctors may inject a dye into your blood vessels to highlight the heart and blood vessels in images (magnetic resonance angiography). Doctors may use this test to measure the size of your aorta.

These tests and others help your doctor determine how narrow or tight your aortic valve may be and how well your heart is pumping. Once aortic valve stenosis is discovered, your doctor will either recommend treatment or suggest careful monitoring.

Treatments and drugs

Medications sometimes can ease symptoms of aortic valve stenosis. However, the only way to eliminate aortic valve stenosis is surgery to repair or replace the valve and open up the passageway.

Surgery isn't always needed right away. If tests reveal that you have mild to moderate aortic valve stenosis and you have no symptoms, your doctor will schedule checkups to carefully monitor the valve so that surgery can be done at the appropriate time. In follow-up appointments, your doctor will review your medical history and conduct a physical examination. Your doctor may also discuss symptoms and what to expect as your condition progresses.

Your doctor may order an echocardiogram to view your aortic valve and monitor your condition every three to five years if you have mild aortic valve stenosis, and every year if you have moderate aortic valve stenosis.

If you have severe aortic valve stenosis, your doctor may schedule checkups every three to six months. Your doctor may order an echocardiogram every six to 12 months to view your heart valve and monitor your condition. In some cases, your doctor may order additional tests.

In general, surgery is necessary when narrowing becomes severe and symptoms develop. In some cases, your doctor may recommend surgery if you have severe aortic valve stenosis even if you aren't experiencing symptoms. If you have moderate or severe aortic valve stenosis and other conditions that require heart surgery, your doctor may recommend surgery to treat your conditions.

Medications

No medications can reverse aortic valve stenosis. However, your doctor may prescribe certain medications to help your symptoms, such as ones to reduce fluid accumulation, to slow your heart rate or to control heart rhythm disturbances associated with aortic valve stenosis. Lowering blood pressure may prevent or slow the development of aortic stenosis. Ask your doctor if you need to lower your blood pressure with medications.

Procedures

You may need valve repair or replacement to treat aortic valve stenosis. Although less invasive approaches are possible in some cases, surgery is the primary treatment for this condition.

Therapies to repair or replace the aortic valve include:

  • Balloon valvuloplasty. Occasionally, balloon valvuloplasty is an option. Balloon valvuloplasty uses a soft, thin tube (catheter) tipped with a balloon.

A doctor guides the catheter through a blood vessel in your groin to your heart and into your narrowed aortic valve. Once in position, a balloon at the tip of the catheter is inflated. The balloon pushes open the aortic valve and stretches the valve opening, improving blood flow. The balloon is then deflated, and the catheter with the balloon is guided back out of your body.

Balloon valvuloplasty may relieve aortic valve stenosis and its symptoms, especially in infants and children. However, in adults, the valve tends to narrow again even after initial success. For these reasons, doctors rarely use balloon valvuloplasty today to treat aortic valve stenosis in adults, except in people who are too sick to undergo surgery or are waiting for a transcatheter aortic valve replacement.

  • Aortic valve replacement. This is the primary surgical treatment for severe aortic valve stenosis. Your surgeon removes the narrowed aortic valve and replaces it with a mechanical valve or a tissue valve. This procedure is generally performed during open-heart surgery.

Mechanical valves, made from metal, are durable, but they carry the risk of blood clots forming on or near the valve. If you receive a mechanical valve, you'll need to take an anticoagulant medication, such as warfarin (Coumadin), for life to prevent blood clots.

Tissue valves — which may come from a pig, cow or human deceased donor — often eventually narrow over the years and need to be replaced. Another type of tissue valve replacement that uses your own pulmonary valve (autograft) is sometimes possible but less likely in an older person. Your doctor can discuss the risks and benefits of each type of heart valve with you. Aortic valve replacement can relieve aortic valve stenosis and its symptoms.

  • Transcatheter aortic valve replacement (TAVR). Aortic valve replacement, the most common treatment for aortic valve stenosis, has traditionally been performed with open-heart surgery.

A less invasive approach — transcatheter aortic valve replacement — involves replacing the aortic valve with a prosthetic valve via the femoral artery in your leg (transfemoral) or the left ventricular apex of your heart (transapical).

In TAVR, doctors insert a catheter with a balloon at the tip in an artery in your leg or in a small incision in your chest and guide it to your heart and into your aortic valve. A balloon at the tip of the catheter, which has a folded valve around it, is then inflated. This pushes open the aortic valve and stretches the valve opening and expands the folded valve into the aortic valve. Doctors then deflate the balloon and guide the catheter with the balloon back out of your body. Alternatively, a self-expanding valve may be inserted into the aortic valve, and a balloon then isn't used.

In some cases, a valve can be inserted via a catheter into a tissue replacement valve that needs to be replaced (valve-in-valve procedure).

TAVR is usually reserved for individuals with severe aortic valve stenosis who are at increased risk of complications from aortic valve surgery. This procedure can relieve severe aortic valve stenosis and its symptoms in those who are at increased risk of complications from aortic valve surgery. TAVR has a higher risk of stroke and vascular complications than aortic valve replacement surgery. The technique is relatively new and is evolving quickly, and there are newer valves and indications occurring frequently. TAVR is sometimes referred to as transcatheter aortic valve implantation (TAVI).

  • Surgical valvuloplasty. In rare cases, surgical repair may be a more effective option than balloon valvuloplasty, such as in infants born with an aortic valve in which the leaflets of the valve are fused together. Using traditional surgical tools, a cardiac surgeon operates on the valve and separates these leaflets to reduce stenosis and improve blood flow.

Aortic valve stenosis can be treated effectively with surgery. However, you'll need regular follow-up appointments with your doctor to check for any changes in your condition. You may still be at risk of irregular heart rhythms even after you've been treated for aortic valve stenosis. You may need to take medications to lower that risk. If your heart has become weakened from aortic valve stenosis, you may need medications to treat heart failure.

If you've had aortic valve replacement surgery, you need to take antibiotics before certain dental or medical procedures due to the risk of infection in your heart tissue (endocarditis)

Aortic valve regurgitation

Aortic valve regurgitation — or aortic regurgitation — is a condition that occurs when your heart's aortic valve doesn't close tightly. Aortic valve regurgitation allows some of the blood that was just pumped out of your heart's main pumping chamber (left ventricle) to leak back into it.

The leakage may prevent your heart from efficiently pumping blood to the rest of your body. As a result, you may feel fatigued and short of breath.

Aortic valve regurgitation can develop suddenly or over decades. Once aortic valve regurgitation becomes severe, surgery is often required to repair or replace the aortic valve.

Tests and diagnosis

Your doctor will ask about your and your family's medical history and give you a physical exam that includes listening to your heart with a stethoscope. Aortic valve regurgitation usually produces a heart murmur, the sound of blood leaking backward through the aortic valve.

Your doctor will then decide what tests are needed to make a diagnosis. For testing, you may be referred to a cardiologist.

Diagnostic tests

Other heart problems can cause signs and symptoms similar to those of aortic valve regurgitation, and it's possible to have more than one disorder at once. Common tests doctors use to diagnose aortic valve regurgitation include:

  • Echocardiogram. Sound waves directed at your heart from a wand-like device (transducer) held on your chest produces video images of your heart in motion. An echocardiogram can identify aortic valve regurgitation and determine its severity.
  • Exercise tests. Different types of exercise tests help measure your tolerance for activity and check your heart's response to exertion.
  • Cardiac magnetic resonance imaging. Using a magnetic field and radio waves, this test produces detailed pictures of your heart, including the aortic root.
  • Electrocardiogram (ECG). Wires (electrodes) attached to adhesive pads on your skin measure electrical impulses from your heart, providing information about your heart rhythm. You might walk on a treadmill or pedal a stationary bike during an ECG to see how your heart responds to exertion.
  • Chest X-ray. This enables your doctor to determine whether your heart is enlarged — a possible indicator of aortic valve regurgitation — and the condition of your lungs.
  • Cardiac catheterization. When noninvasive tests are inconclusive, this invasive technique provides a more detailed picture of your heart. It involves threading a thin tube (catheter) through a blood vessel in your arm or groin to an artery in your heart and injecting dye through the catheter to make the artery visible on an X-ray.

These tests help your doctors diagnose aortic valve regurgitation, determine how serious the problem is, and decide whether your aortic valve needs repair or replacement.

Treatments and drugs

Treatment of aortic valve regurgitation depends on how severe your regurgitation is, your signs and symptoms, and whether the regurgitation is affecting your heart function.

Observation

Some people, especially those with mild regurgitation, may not need treatment. However, the condition may require monitoring by your doctor. You may need regular evaluations, with the frequency depending on how severe your condition is.

Surgery

Your aortic valve may need surgical repair or replacement, even if it's not causing symptoms. While the heart is generally good at counteracting problems caused by a leaky aortic valve, if the valve isn't fixed or replaced in time, your heart may weaken permanently.

Heart valve surgery should be done at a high-volume heart valve surgery center with a reputation of excellence, and cardiologists, imaging specialists and cardiac surgeons with experience in treating heart valve conditions.

Discuss the risks and benefits of surgery with your doctor. Your surgery options include:

  • Valve repair. Aortic valve repair is surgery to preserve the valve and to improve its function. Occasionally, surgeons can modify the original valve (valvuloplasty) to eliminate backward blood flow.
  • Valve replacement. In many cases, the aortic valve has to be replaced with a mechanical valve or a tissue valve. Mechanical valves, made from metal, are durable, but carry the risk of blood clots forming. If you receive a mechanical aortic valve, you'll need to take an anticoagulant medication, such as warfarin (Coumadin), for life to prevent blood clots.

Tissue valves — which may come from a pig, cow or human cadaver donor — often eventually need replacement. Another type of tissue valve replacement that uses your own pulmonary valve (autograft) is sometimes possible.

Less invasive techniques

Aortic valve replacement generally requires open-heart surgery under general anesthesia and with the use of a heart-lung bypass machine. Less invasive surgical techniques, such as using a small, lighted tube through a small incision to see the surgical area (laparoscopy), are being explored for aortic valve surgery.

Minimally invasive cardiac surgery is associated with less pain, a shorter hospital stay and fewer complications. However, the surgery is more complex than open-heart surgery, partly because the surgeon can't see the valve as well. Talk to your surgeon to see if this type of surgery might be right for you.