How is aortic valve stenosis treated?

Dr. Daniel P. O'Hair, MD
Cardiothoracic Surgeon

Surgical replacement of the valve for treatment of aortic stenosis has been the standard of care for 40 years.

However, there are other treatment options. In some patients you can use a balloon (valvuloplasty). Using a catheter-based approach (in which a tube is placed in a vessel and a wire is guided to the problem area), a balloon is inserted into the valve to enlarge the valve. It is not a good long-term strategy, but it helps people who are suddenly ill from their condition, for example, if their blood pressure drops.

In another catheter-based approach, a valve, very similar to one used in the surgery option, is placed on a stent, or small metal cage, and pushed up into the heart. The stent is opened, putting the new valve in place.

Dr. Brian K. Whisenant, MD
Cardiologist (Heart Specialist)

Once aortic stenosis becomes symptomatic and severe it demands replacement. This is traditionally performed with open heart surgery.  Recent research has demonstrated the success of less invasive valve replacement using catheter base technologies.

For people with severe aortic valve stenosis who have symptoms, the traditional treatment is minimally invasive aortic valve replacement (AVR), either surgical or transcatheter. Clinical guidelines from the American Heart Association and the American College of Cardiology recommend “active surveillance” in people with asymptomatic aortic stenosis, unless stress testing can expose symptoms. Historically, the management for asymptomatic aortic stenosis includes the accepted practice of watchful waiting (WW) and delaying AVR until the development of symptoms. However, minimally invasive AVR reduces the risks associated with open heart surgery and decreases the recuperation time, making it a viable option for earlier treatment of people who have no symptoms.

Mild cases of aortic valve stenosis usually do not require treatment. However, ongoing monitoring is important to determine any changes. If aortic valve stenosis is moderate or severe, a heart specialist known as an interventional cardiologist may be able to use a thin, flexible balloon-tipped tube called a dilation catheter to separate the fused valve flaps (the leaflets). As the balloon expands, its pressure stretches the valve tissue to create a wider passage. This process increases blood flow through the aortic valve and to the rest of the body. This procedure is performed in the cardiac catheterization laboratory (or “cath lab”) of the hospital.

Critical aortic stenosis requires immediate medical attention. This usually involves treating the infant with a medication that keeps open the patent ductus arteriosis (PDA), a passage between the two major arteries of the heart that is present in all babies before birth. The PDA normally closes by itself shortly after birth after the baby begins to breathe air. The medication (prostaglandin E1) keeps the PDA open, allowing the aortic valve to be bypassed until the aortic valve can be widened to establish normal circulation.

Dr. Abdul J. Tajik, MD
Cardiologist (Heart Specialist)

There are no medications that can reverse or cure aortic stenosis (narrowing of the aortic valve). However, there are medications prescribed to control blood pressure, treat rhythm disturbances, minimize symptoms, maximize your heart’s ability to pump blood and slow the progression of the disease. If you don’t have any symptoms, your healthcare provider may choose to watch you over time with periodic examinations provided the aortic stenosis is not severe.

Beta-blockers are the most prescribed medication because they help control blood pressure and slow the heart rate, which allows more time for the left ventricle to fill with blood. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) may be prescribed to control blood pressure, improve symptoms and enhance heart muscle function. Research is ongoing in the area of disease progression. Some studies have indicated that treatment of cholesterol will halt or slow the progression of the disease. Therefore, your healthcare provider may recommend a statin medication and/or over-the-counter fish oil to treat your cholesterol level.

When medication therapy is not successful in relieving symptoms, other treatment options are considered. Balloon valvuloplasty is an invasive procedure that is done to temporarily relieve symptoms and reduce the obstruction from aortic stenosis. This treatment is usually reserved for children, patients who are very young or older patients who are at risk for surgical procedures.

Surgical replacement of the aortic valve is the standard of treatment for aortic stenosis, and provides the best long-term solution for treating aortic valve disease. The valve can be replaced with a mechanical or bioprosthetic valve.

A less invasive procedure called transcatheter aortic valve implantation (TAVI) is currently being performed in the United States. During this procedure, the aortic valve is delivered via a catheter from the groin, thereby not requiring open heart surgery.

Subaortic or supra-aortic obstructions are treated by surgically removing the abnormal additional tissue. Aortic valve replacement combined with this procedure may be necessary. If the left ventricle walls have become too thick below the aortic valve, a myectomy may be performed. This involves cutting away excess muscle.

The symptoms of aortic stenosis (AS) can be managed through medication prescribed by your doctor but AS cannot be cured by taking medication. AS is a very aggressive disease and once it reaches the severe stage medical intervention is required as the two year survival rate for symptomatic aortic stenosis is less than 50 percent.

Open heart surgery is the gold standard for treating AS due to the excellent results of this therapy. The surgeon performs an incision down the center of the breastbone to access the heart or through a less invasive approach, using a small incision to access the aortic valve. The diseased valve is carefully removed and a new aortic valve is sown into its place restoring normal functioning. The aortic valve is replaced with a bioprosthetic (tissue) or mechanical valve.

Transcatheter aortic valve replacement (TAVR) is also available for patients who have severe aortic stenosis and are considered inoperable or high risk for surgical intervention. A prosthetic valve is delivered to the heart through a catheter, a tube-based delivery system, guided by x-ray and ultrasound. The prosthetic valve is carefully positioned, expanded and anchored inside the patient’s own valve. The diseased leaflets are pushed aside and replaced with the new valve which begins to function immediately. The valve can be advanced to the heart either through the femoral artery (groin) or through a small incision just above the breast bone (transapical approach) and physicians are currently investigating a new access route in a clinical trial which accesses the valve through the top of the breast bone called the transaortic approach.

Treatment of aortic stenosis depends on your symptoms and may include one or more of the following:

  • Surgery: Surgery is the only treatment to cure aortic stenosis. The procedures may include an aortic valve replacement, aortic valve repair or aortic balloon valvuloplasty. Ask your healthcare provider for more information about these procedures.
  • Medicines: Medicines are given to prevent further damage to the aortic valves that may lead to other problems. Other medicines may be given to treat symptoms.

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.