When should asymptomatic patients with combined severe aortic stenosis and aortic insufficiency undergo valve replacement? A clinical case

Indications to prosthetic aortic valve implantation in patients with aortic stenosis or aortic regurgitation or both stenotic or regurgitant aortic valve, who present without symptoms, are controversial. We present the case of an asymptomatic patient with combined severe aortic stenosis and an equally important insufficiency, undergoing surgery for valve substitution with a bileaflet prosthesis. After surgery he was treated with warfarin according to the doses recommended and underwent follow-up with clinical and echocardiographic exams. Eight months after intervention the patient had an embolic stroke with aphasia and right hemiplegia, despite the therapeutic level of INR. At present, even though he has partly recovered motor function, he reports a noteworthy decline in life quality, because of the persistent speech difficulties. We use this case as the starting point for a discussion of the chance of referring patients affected by aortic valvulopathy to valve substitution, in the absence of symptoms.     

Recurrent gastrointestinal bleeding and aortic valve stenosis (Heyde syndrome): need for valve replacement?

Angiodysplasia are common in patients over the age of 60. Heyde syndrome describes the coincidence of aortic valve stenosis and gastrointestinal bleeding from angiodysplasia. We describe one characteristic case of aortic valve stenosis and gastrointestinal bleeding from angiodysplasia which subsided after replacement with an aortic valve bioprosthesis. We review the current literature and discuss the actual explanation approaches for this phenomenon. CONCLUSION: There seems to be a clear indication for valve replacement in the case of aortic valve-stenosis and gastrointestinal bleeding due to angiodysplasia.     

What influences the outcome of valve replacement in critical aortic stenosis?

Even patients with severely reduced left ventricular function and critical aortic stenosis can improve notably following valve replacement.     

Asymptomatic adult patients with aortic stenosis: should they ever have aortic valve replacement?

Presently, conventional wisdom is that an asymptomatic patient, even with severe aortic stenosis (AS), can be followed medically. The basis for this recommendation is that sudden death as the first "symptom" in an asymptomatic patient is rare. Unfortunately, symptoms are subjective and can be ignored or explained away by both patient and physician, and once symptoms are recognized, sudden death accounts for at least one third of the deaths from AS in unoperated patients. There is evidence that once AS becomes severe, ischemia and fibrosis occur rapidly, setting up the possibility of heart failure and sudden death even after successful valve replacement. Aortic valve replacement should be performed before extensive fibrosis occurs. Multiple studies have shown that in severe AS, symptoms will occur rapidly when there is heavy valve calcification, an aortic valve area <0.8 cm, an annual rate of progression of aortic valve velocity of >/=0.3 m/sec, or a positive exercise stress test. These findings are excellent evidence that asymptomatic patients with severe AS and any of the above findings should be considered for aortic valve replacement.     

Does aortic valve replacement mitigate the risk of preoperative heart failure?

Congestive heart failure complicating aortic valve disease has been reported to increase the operative mortality associated with aortic valve replacement. To determine whether this adverse effect remains late after aortic valve replacement, we analyzed prospectively collected and survival data of 849 patients who underwent aortic valve replacement between 1999 and 2008. There were 243 (29%) cases of heart failure preoperatively (138 current and 105 prior). Both operative and late mortality rates (up to 10 years) were significantly higher in heart failure patients. Current congestive heart failure caused a 3-fold increase in operative mortality and an 86% increase in late mortality, whereas previous history of heart failure caused a doubling of late mortality. Preoperative heart failure still compromises early and late survival after aortic valve replacement. Surgery should be considered early in patients with aortic valve disease and deferred, when possible, in those with frank heart failure.     

Does aortic valve sclerosis predicts the severity and complexity of coronary artery disease?

Aim

We assessed the association of aortic valve sclerosis (AVS) with atherosclerotic risk factors and severity and complexity of coronary artery disease (CAD).

Methods

In this retrospective study, a total of 482 eligible patients were divided into 2 groups: AVS present and AVS absent. All major cardiovascular risk factors and coronary lesion characteristics were included.

Results

Age was the only independent predictor of AVS. AVS was not independently associated with the number of obstructive vessels, degree of lesion obstruction and SYNTAX score.

Conclusion

AVS is probably a benign marker of age-related degenerative changes in the heart independent of the severity and complexity of CAD.