Aortic stenosis (patient information)

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Overview
The aorta is the main artery leaving the heart. When blood leaves the heart, it flows from the lower chamber (the left ventricle), through the aortic valve, into the aorta. In aortic stenosis, the aortic valve does not open fully. This restricts blood flow from the heart to the rest of the body.

What are the symptoms of Aortic stenosis?
You may have no symptoms at all until late in the course of the disease. The diagnosis may have been made when your healthcare provider heard a heart murmur and then performed additional tests.

Symptoms in Adults:
 * Breathlessness with activity.
 * Chest pain, which resembles what is known as angina-type pain.
 * The pain is crushing, squeezing, pressure or tightness in nature.
 * The pain increases with exercise, relieved with rest.
 * The patient feels pain under the chest bone, it may move to other areas.
 * Fainting, weakness, or dizziness with activity.
 * Sensation of feeling the heart beat (palpitations).

Symptoms in Infants and children: Children with mild or moderate aortic stenosis may get worse as the get older. They also run the risk of developing an infection of the heart valves (bacterial endocarditis).
 * Becoming tired or fatigued with exertion more easily than others (in mild cases)
 * Serious breathing problems that develop within days or weeks of birth (in severe cases)
 * Extremely tired
 * Sweaty
 * Pale skin
 * Fast breathing
 * They may also be smaller than other children their age

What causes Aortic stenosis?
In the United States, aortic stenosis often results from calcium deposits on the aortic valve. These deposits occur naturally with age and have no relationship with the amount of calcium in the diet. Approximately 2% of all people have a bicuspid aortic valve, which increases the risk of these calcifications and makes them more likely to develop aortic stenosis. Worldwide, aortic stenosis occurs most commonly in those who've had rheumatic fever, a condition that may develop after strep throat or scarlet fever. Valve problems do not develop for 5 - 10 years or longer after rheumatic fever occurs. Rheumatic fever is increasingly rare in the United States.

Aortic stenosis may be present from birth (congenital), or it may develop later in life (acquired). Children with aortic stenosis may have other congenital conditions. Radiation treatment to the chest, and some medications may cause aortic stenosis. Aortic stenosis is not common. It occurs more often in men than in women.

As the aortic valve becomes more narrow, the pressure increases inside the lower chamber of the heart (the left ventricle). This causes the left ventricle to become thicker, decreasing blood flow and can lead to chest pain. As the pressure continues to rise, blood may back up into the lungs, and you may feel short of breath. Severe forms of aortic stenosis prevent enough blood from reaching the brain and rest of the body. This can cause lightheadedness and fainting.

Who is at highest risk?
Aortic stenosis occurs more often in men than in women. The calcifications that cause most cases of aortic stenosis are more likely to occur in patients above the age of 50, who are overweight, who smoke, and who have diabetes, high blood pressure, and high cholesterol. These are the same risk factors for atherosclerosis of the coronary blood vessels.

People who had rheumatic fever as a child also have a somewhat higher risk of developing aortic stenosis, but rheumatic fever is very rare in the United States. Radiation therapy for treatment of cancer, such as breast cancer or lymphoma, may also increase the risk of aortic stenosis.

Diagnosis

 * Heart murmur: When listening to your heart, your health care provider may hear a new heart murmur associated with aortic stenosis. This murmur is not always there in aortic stenosis. If a new murmur is heard and your health care provider is concerned about aortic stenosis or another form of heart disease, further tests may be ordered. It is important to remember that not all heart murmurs mean you have a harmful heart condition.
 * Blood pressure: You may have high blood pressure if you have mild aortic stenosis. In rare cases of severe aortic stenosis, your blood pressure may actually be low.
 * Tests:
 * Chest x-ray
 * Electrocardiogram. Sensors on the chest measure electrical activity of the heart.
 * Echocardiography. It is an ultrasound of the heart.
 * Exercise stress testing. Your doctor monitors your electrocardiogram while you exercise.
 * MRI of the heart. You lay in a magnet that takes pictures of your heart.
 * Cardiac catheterization. A catheter is inserted into the arteries of your heart and pictures are taken.

When to seek urgent medical care?
Call your health care provider if you or your child have symptoms of aortic stenosis. For example, call if you or your child have increasing shortness of breath, chest pain or fainting.

Also contact your doctor if you have been diagnosed with this condition and your symptoms get worse or new symptoms develop.

Treatment options
If there are no symptoms or symptoms are mild, you may only need to be monitored by a health care provider. Patients with aortic stenosis may be told not to play competitive sports, even if they don't have symptoms. If symptoms do occur, strenuous activity must be limited.

In adults, treatments include:
 * Medication: Medications are used to treat symptoms of heart failure or abnormal heart rhythms (most commonly atrial fibrillation). These include diuretics (water pills), nitrates, and beta-blockers. High blood pressure should also be treated.
 * Lifestyle changes: Stop smoking and be treated for high cholesterol. See a cardiologist every 3 to 6 months.
 * Surgery: Surgery to repair or replace the aortic valve is the preferred treatment for adults or children who develop symptoms. Even if symptoms are not very bad, the doctor may recommend surgery. People with no symptoms but worrisome results on diagnostic tests may also require surgery.
 * Valvuloplasty: Some high-risk patients may be poor candidates for heart valve surgery. A less invasive procedure called balloon valvuloplasty may be done in adults or children instead. This is a procedure in which a balloon is placed into an artery in the groin, advanced to the heart, placed across the valve, and inflated. This may relieve the obstruction caused by the narrowed valve.
 * Percutaneous Aortic Valve Replacement: Percutaneous aortic valvular replacement (PAVR) is a new less invasive procedure that does not require open heart surgery. In this procedure, a new replacement or prosthetic valve is implanted into the heart. The device is inserted through a small hole in the artery that runs to the leg . It is a relatively new procedure and is currently under study. It has the benefits of not requiring general anesthesia, causing less pain, less blood loss, and a lower risk of infection. There is also a faster recovery after PAVR than with traditional open heart surgery to replace the aortic valve.

In children, treatments include:
 * Physically activity limits: Children with mild aortic stenosis may be able to participate in most activities and sports. As the illness progresses, sports such as golf and baseball may be permitted, but not more physically demanding activities.
 * Surgery: Valvuloplasty is often the first-choice for surgery in children. Some children may require aortic valve repair or replacement. If possible, the pulmonary valve may be used to replace the aortic valve, called a Ross procedure.

Where to find medical care for Aortic stenosis?
Directions to Hospitals Treating Aortic stenosis

What to expect (Outlook/Prognosis)?
People with mild aortic stenosis may do very well using a watchful waiting approach with their health care provider. They may be treated medically for some conditions associated with aortic stenosis, such as high blood pressure, and may have a normal life expectancy.

Those with more severe symptoms, such as chest pain or signs of heart failure like shortness of breath and leg swelling, generally do poorly without surgery. However, surgery does have the potential to cure a person's aortic stenosis. The success of surgery depends on a number of factors, including patient age, overall activity level, and presence of other medical conditions. As with any operation, aortic valve surgery has some risks, most of which occur during the first 1-2 days after surgery. These include an irregular heart rhythm and blood clots in the legs. There is also a chance that the new or repaired valve may stop working which might require another surgery.

Prevention
Treat strep throat promptly to prevent rheumatic fever, which can cause aortic stenosis.

Follow your health care provider's treatment recommendation for conditions that may cause valve disease. Notify you provider if there is a family history of congenital heart diseases.

Possible complications

 * Arrhythmias.
 * Endocarditis.
 * Left-sided heart failure.
 * Left ventricular hypertrophy (enlargement) caused by the extra work of pushing blood through the narrowed valve.