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Aortic Valve Stenosis

Aortic Stenosis

Aortic stenosis is a progressive valvular disease, resulting in obstruction of blood flow through the aortic valve. One of the most prevalent heart diseases in the Western world, aortic stenosis is attributed to degenerative calcification of the valvular leaflets in senior patients. However, in the younger population, aortic stenosis typically results from a congenital bicuspid valve.


Presentation

The clinical picture consists of the SAD triad: syncope upon physical exertion, angina and dyspnea. Other symptoms associated with AS are related to cardiac failure, such as paroxysmal nocturnal dyspnea, orthopnea, and dyspnea on exertion. Arrhythmias such as the potentially fatal ventricular fibrillation can also occur.

Exertional syncope, which is the most common complaint, stems from the inability of CO to meet physical demands in the setting of systemic vasodilatation. Seizures can occur with syncopic phenomena [6].

Heart failure may develop from various pathophysiological mechanisms such as diastolic or systolic dysfunction. The former is a consequence of LVH or ischemia, while systolic failure is a result of afterload mismatch, ischemia or another pathological condition. Finally, tachyarrhythmias and heart blocks can also contribute to heart failure.

Other complications include gastrointestinal bleeding secondary to angiodysplasia and symptomatology consistent with bacterial endocarditis. Also, aortic stenosis can produce calcium emboli, even though such a complication is rare. 

Physical Exam
A physical exam reveals findings consistent with aortic stenosis. Patients tend to exhibit diminished carotid and peripheral pulses. Moreover, the clinician can palpate a sustained apical impulse, which is indicative of LVH. 

Regarding cardiac auscultation, the characteristic murmur reflects a crescendo-decrescendo ejection pattern. This is heard at the right and left upper sternal border as the patient tilts forward while sitting.

Fatigue
  • However, if family members notice a decline in routine physical activities or significant fatigue, it is worth a visit to your healthcare provider to check for the possibility of reduced heart function.[heart.org]
  • Heart failure signs and symptoms include fatigue, shortness of breath, and swollen ankles and feet. When to see a doctor If you have a heart murmur, your doctor may recommend that you visit a cardiologist.[mayoclinic.org]
  • Eventually, the pressure can lead to heart failure, fatigue and dizziness. Aortic stenosis can occur when calcium builds up on the valve over several years, making it thick and hard.[uabmedicine.org]
Congestive Heart Failure
  • Abstract A 56-year-old female with congestive heart failure was transferred to our institution. Aortography demonstrated aortic valve stenosis (AS) with a congenitally bicuspid valve and dilatation of the ascending aorta.[ncbi.nlm.nih.gov]
  • The occurrence of AS-related events (sudden death, congestive heart failure or new onset of symptoms) within two years was recorded prospectively. RESULTS: We enrolled 809 patients.[ncbi.nlm.nih.gov]
  • KEYWORDS: aortic stenosis; congestive heart failure; transcatheter aortic valve replacement [Indexed for MEDLINE] Free full text[ncbi.nlm.nih.gov]
  • Tolvaptan (TLV), unlike other diuretics, resulted in modest changes in filling pressures associated with an increase in urine output, suggesting that TLV improves congestive heart failure (CHF) due to severe AS without hemodynamic instability.We retrospectively[ncbi.nlm.nih.gov]
  • When the heart begins to wear out, patients will experience symptoms of congestive heart failure. Patients that have been diagnosed with Aortic Valve Insufficiency must have regular, careful follow up appointments with a cardiologist.[heartsurgeryinfo.com]
Falling
  • Author information 1 Inova Heart and Vascular Institute, 3300 Gallows Rd. 1st floor Suite 1225, Falls Church, VA, 22042, USA. matthew.sherwood@inova.org. 2 Duke Clinical Research Institute, 2400 Pratt Street, P.O.[ncbi.nlm.nih.gov]
  • In other words, if excessive afterload has primarily caused a reduction in ejection fraction, then relief of the valve obstruction will cause a sudden fall in afterload with a substantial rise in ejection fraction.[doi.org]
  • This increased pressure gradient is expressed as an increase in the pressure proximal to the valve and a small fall in pressure distal to the valve.[cvphysiology.com]
  • If congestive heart failure leads to a fall in cardiac output, the murmur will be quieter. An ejection click may be present, especially with bicuspid valves.[patient.info]
Anemia
  • Initially, the picture of anemia was attributed to the IRC. However, there was improvement in renal function after volume infusion, characterizing renal dysfunction as acute. Because of heart failure and anemia, a blood transfusion was made.[scielo.br]
  • […] failure; conduction system defect which may require a permanent pacemaker; arrhythmia; retroperitoneal bleed; arteriovenous(AV) fistula or pseudoaneurysm; reoperation; ischemia or nerve injury; restenosis; pulmonary edema; pleural effusion; bleeding; anemia[edwards.com]
  • Cardiology evaluation should also be considered in patients with subtle or atypical presentations, such as decreased exercise tolerance or an episode of congestive heart failure precipitated by new-onset anemia.[aafp.org]
Pulmonary Valve Stenosis
  • Numerous clinical maneuvers can be used to distinguish aortic stenosis from the similar-sounding murmurs of hypertrophic obstructive cardiomyopathy and pulmonary valve stenosis, such as the Valsalva maneuver and auscultation during inspiration respectively[radiopaedia.org]
Dyspnea
  • Abstract A 74-year-old woman with severe aortic valve stenosis (AS) was admitted to our hospital because of dyspnea on exertion. On day 2, she developed acute anterior wall myocardial infarction (MI) with ST elevation.[ncbi.nlm.nih.gov]
  • Two years after the initial surgery the patient developed progressive dyspnea.[ncbi.nlm.nih.gov]
  • The clinical picture consists of the SAD triad: syncope upon physical exertion, angina and dyspnea. Other symptoms associated with AS are related to cardiac failure, such as paroxysmal nocturnal dyspnea, orthopnea, and dyspnea on exertion.[symptoma.com]
  • ., when it first becomes symptomatic ( dyspnea on exertion, angina pectoris, or syncope ). Auscultation reveals a harsh, crescendo-decrescendo murmur in systole that radiates to the carotids, and pulses are delayed with diminished carotid upstrokes.[amboss.com]
  • Dyspnea is the first symptom of aortic stenosis in about 50% of the cases; syncope and angina account for 35% and 15% of initial symptoms, respectively.[healio.com]
Orthopnea
  • Other symptoms associated with AS are related to cardiac failure, such as paroxysmal nocturnal dyspnea, orthopnea, and dyspnea on exertion. Arrhythmias such as the potentially fatal ventricular fibrillation can also occur.[symptoma.com]
  • The patient also presented dyspnea on minimal exertion, orthopnea, paroxysmal nocturnal dyspnea and edema of lower limbs. The patient denied fever. Patient reported episodes of lower gastrointestinal bleeding (LGIB) in small amounts, for six months.[scielo.br]
  • Other classic symptoms of heart failure — orthopnea, paroxysmal nocturnal dyspnea (PND) and signs of right sided heart failure (i.e. peripheral edema) — are also common.[healio.com]
  • Heart failure Heart failure symptoms (ie, paroxysmal nocturnal dyspnea, orthopnea, dyspnea on exertion, and shortness of breath) may be due to systolic dysfunction from afterload mismatch, ischemia, or a separate cardiomyopathic process.[emedicine.medscape.com]
Exertional Dyspnea
  • Exertional dyspnea is the most common initial complaint, even in patients with normal LV systolic function, and it often relates to abnormal LV diastolic function.[emedicine.medscape.com]
Heart Disease
  • We describe a case of AS with ischemic heart disease of a patient who underwent a successful surgical treatment, AVR combined with the endoventricular patch technique.[ncbi.nlm.nih.gov]
  • KEYWORDS: adult congenital heart disease; aortic valve; calcification; heart failure; repair[ncbi.nlm.nih.gov]
  • This is a rare association, as juxtaposition of atrial appendages is generally associated with more complex forms of congenital heart disease. The patient underwent successful surgery with uneventful postoperative course.[ncbi.nlm.nih.gov]
  • Aortic stenosis (AS) is the most common form of valvular heart disease. AS of degenerative etiology is predominant. It is a persistent disease associated with the activation of 3 processes: lipid accumulation, inflammation, and calcification.[ncbi.nlm.nih.gov]
  • Aortic stenosis (AS), a potentially life-threatening heart disease, is characterized by the obstruction of blood flow across the aortic valve.[symptoma.com]
Chest Pain
  • A 69-year-old man presented with shortness of breath and exertional chest pain.[ncbi.nlm.nih.gov]
  • Tissue plasminogen activator (tPA) was administered 10 min after the onset of chest pain, and emergency percutaneous coronary intervention was performed to induce coronary reperfusion after another 50 min.[ncbi.nlm.nih.gov]
  • Three years later, she had chest pain on effort and angina pectoris was diagnosed by coronary angiography. At that time, she underwent coronary artery bypass grafting surgery with 2 saphenous vein grafts (SVG).[ncbi.nlm.nih.gov]
  • Patients feel shortness of breath, dizziness, and chest pain. 2018 Intermountain Healthcare. All rights reserved. The content presented here is for your information only.[intermountainhealthcare.org]
  • Common symptoms of aortic stenosis and regurgitation include fainting, weakness or chest pain (often increasing with activity), palpitations (rapid, noticeable heart beats) and chronic heart failure.[emoryhealthcare.org]
Heart Murmur
  • There are usually no other symptoms, although a heart murmur can be heard. Abnormal sounds caused by the closing of the valve may also be heard. A complication of the condition can be an infection in the heart.[cedars-sinai.edu]
  • Mild aortic stenosis is usually picked up at a routine postnatal or six-week check-up alongside a heart murmur (an additional heart sound). In severe cases, the child may experience breathlessness and not be feeding properly.[gosh.nhs.uk]
  • A heart murmur, click, or other abnormal sound is almost always heard through a stethoscope. The provider may be able to feel a vibration or movement when placing a hand over the heart.[nlm.nih.gov]
  • When to see a doctor If you have a heart murmur, your doctor may recommend that you visit a cardiologist. If you develop any symptoms that may suggest aortic valve stenosis, see your doctor.[mayoclinic.org]
Palpitations
  • Common symptoms of aortic stenosis and regurgitation include fainting, weakness or chest pain (often increasing with activity), palpitations (rapid, noticeable heart beats) and chronic heart failure.[emoryhealthcare.org]
  • When symptoms appear, they are usually triggered by exercise and may include: Angina Dizziness Faintness Heart palpitations Shortness of breath, tiredness Another sign of aortic stenosis is a heart murmur, which may be detected by your doctor during a[mainlinehealth.org]
  • Feeling dizzy or faint Feeling tired and being short of breath – even at rest A feeling that your heart is pounding, racing, or beating unevenly (palpitations).[phoebehealth.com]
  • Symptoms of aortic stenosis may include: Breathlessness Chest pain (angina), pressure or tightness Fainting, also called syncope Palpitations or a feeling of heavy, pounding, or noticeable heartbeats Decline in activity level or reduced ability to do[heart.org]
Systolic Murmur
  • 3/6 or louder systolic murmur.[aafp.org]
  • Systolic murmur The classic crescendo-decrescendo systolic murmur of aortic stenosis begins shortly after the first heart sound. The intensity increases toward mid systole, then decreases, and the murmur ends just before the second heart sound.[emedicine.medscape.com]
  • ) murmur that is heard on praecordial auscultation 1,2.[radiopaedia.org]
  • Both conditions are associated with an early, harsh systolic murmur that is transmitted to the carotids. A similar murmur may occur without stenosis if turbulence is due to aortic aneurysm causing dilation of the proximal aorta.[patient.info]
Dizziness
  • Patients feel shortness of breath, dizziness, and chest pain. 2018 Intermountain Healthcare. All rights reserved. The content presented here is for your information only.[intermountainhealthcare.org]
  • When symptoms appear, they are usually triggered by exercise and may include: Angina Dizziness Faintness Heart palpitations Shortness of breath, tiredness Another sign of aortic stenosis is a heart murmur, which may be detected by your doctor during a[mainlinehealth.org]
  • Feeling dizzy or faint Feeling tired and being short of breath – even at rest A feeling that your heart is pounding, racing, or beating unevenly (palpitations).[phoebehealth.com]
  • Common symptoms are tiredness, dizziness, shortness of breath, chest pain or discomfort, and a fast heart beat. A pediatric cardiologist usually diagnoses and manages aortic stenosis.[texaschildrens.org]
  • Eventually, the pressure can lead to heart failure, fatigue and dizziness. Aortic stenosis can occur when calcium builds up on the valve over several years, making it thick and hard.[uabmedicine.org]

Workup

A vital component of the workup is a detailed medical history as it can confirm suspicion arising from a patient’s clinical presentation and co-evaluate underlying health conditions. In addition, a physical exam including careful auscultation can provide important clues.

While the diagnosis is established clinically, there are indicated studies as well. A 2-D transthoracic echocardiogram is the initial test for the classic presentation of aortic stenosis [7]. This demonstrates stenosis, measures LV wall thickness, and detects the severity of systolic dysfunction, alongside the diagnosis of any other valvular disorders or cardiac conditions. A doppler echocardiogram can quantify the jet velocity and transvalvular gradient, thus illustrating the severity of the stenosis.

Cardiac catheterization is also required, in order to determine the presence of coronary artery disease (CAD). An electrocardiogram (ECG) is necessary since it depicts arrhythmias, ischemic changes, and LVH. Moreover, an exercise stress test can be performed in asymptomatic cases but not in symptomatic patients.


Other helpful imaging modalities include radiographs and CT scans. A chest x-ray is obtained to detect congestive heart failure, the size of the heart, and the presence of calcification in the aortic valves. X-ray findings in early and late aortic stenosis differ. In the latter case, it may show cardiomegaly, edema, and other findings suggestive of congestive heart failure. Finally, cardiac CT displays aortic valve calcification which may be correlated with severe stenosis [8].

Calcified Aortic Valve
  • Operative findings included ochronosis of a severely calcified aortic valve and the aortic intima, and bioprosthetic AVR and CABG were successfully performed.[ncbi.nlm.nih.gov]
  • This condition has been known to pathologists as calcareous or calcified aortic valve stenosis, calcific sclerosis of the aortic valve, atherosclerotic calcification of the aortic valve, calcific nodular valvular sclerosis, Mönckeberg's FULL TEXT[annals.org]
  • Rheumatic Aortic Valve Stenosis Degenerative Rheumatic Calcified Aortic Valve Stenosis Mixed Rheumatic Aortic valve Disease (with fish-mouth narrow rigid orifice)[cthsurgery.com]
  • When the leaflets don’t fully open, the heart must work harder to push blood through the calcified aortic valve. Eventually, the heart’s muscles weaken, increasing the patient’s risk of cardiac stress and heart failure.[phoebehealth.com]
  • When the leaflets don’t fully open, the heart must work harder to push blood through the calcified aortic valve. Eventually, the heart’s muscles weaken, increasing the patient’s risk of heart failure.[rwjuh.edu]
Left Axis Deviation
  • ., left axis deviation, positive Sokolow-Lyon index ) Chest x-ray Findings of left ventricular hypertrophy, such as left ventricular enlargement and rounded heart apex, usually only in decompensated aortic stenosis, and possibly left atrial enlargement[amboss.com]
T Wave Inversion
  • At this point there may be signs of ventricular strain pattern (ST segment depression and T wave inversion) on the EKG, suggesting subendocardial ischemia.[en.wikipedia.org]
Left Ventricular Hypertrophy
  • BACKGROUND: Myocardial oxygen consumption (MVO 2 ) and its coupling to contractile work are fundamentals of cardiac function and may be involved causally in the transition from compensated left ventricular hypertrophy to failure.[ncbi.nlm.nih.gov]
  • KEYWORDS: Aortic stenosis; Global longitudinal strain; Left ventricular hypertrophy; Myocardial fibrosis; ST2[ncbi.nlm.nih.gov]
  • References: [3] [7] [4] Diagnostics ECG Nonspecific for AS Signs of left ventricular hypertrophy (e.g., left axis deviation, positive Sokolow-Lyon index ) Chest x-ray Findings of left ventricular hypertrophy, such as left ventricular enlargement and rounded[amboss.com]
  • A S4 heart sound is also often present due to the severe concentric left ventricular hypertrophy that develops in aortic stenosis.[healio.com]

Treatment

AVR constitutes a definitive treatment of symptomatic patients as well as asymptomatic individuals with LV dysfunction. In this procedure, the valve is replaced with a mechanical or prosthetic substitute. In younger individuals, the pulmonic valve can be used to replace the aortic valve, while the pulmonic valve can be substituted by a prosthetic one: this is known as the Ross procedure. Children with severe stenosis may undergo surgery prior to developing symptoms.

While surgical AVR is the optimal therapeutic intervention in the majority of patients, transcatheter valve replacement (TAVR) is the alternative for poor surgical candidates. The TAVR option is safer for high-risk patients and provides improvement to the quality of life and mortality, when compared to treatment with medications. 

As for patients affected by AS and deemed ineligible candidates for a surgical procedure, percutaneous balloon valvuloplasty can be performed for palliative purposes. 

Patients with coexisting coronary heart disease can undergo a combined AVR and bypass graft surgery (CABG).

Drug therapy is challenging in aortic stenosis patients. If vasodilators, such as nitrates, are used, caution should be exercised since these medications can cause hypotension and other physiological effects that may exacerbate stenosis. Any therapy, if indicated, should be utilized carefully. Finally, statins have not demonstrated the capacity to hinder the progression of aortic stenosis [9].

Lastly, individuals with aortic valve stenosis do not require antibiotic prophylaxis for bacterial endocarditis [10].

Prognosis

An aggressive type of AS results in a worse outcome, as the flow through the aortic valve can become substantially diminished. Therefore, patients with aortic stenosis require close follow-up and monitoring. 

The prognosis for patients with severe, symptomatic aortic stenosis is poor, with the average survival rate being 2 to 3 years prior to surgery. Half of the deaths in individuals with severe aortic stenosis are sudden. Hence, patients with this illness should minimize any physical exertion. 

Asymptomatic patients with severe stenosis can remain so for a decade or more, even with LV outflow tract obstruction (LVOTO). The latter may have a genetic component as 20% of patients were observed to have first-degree relatives exhibiting undiagnosed bicuspid aortic valves [4].

The prognosis for asymptomatic patients is excellent. The mortality rate is less than 1% annually. However, 3% to 6% of asymptomatic patients exhibit symptoms every year. A grading classification for aortic valve stenosis provides insight into the clinical outcome in asymptomatic patients [5].

As for surgical intervention in asymptomatic patients, the risks outweigh the benefits. When symptoms present, however, valvular replacement is a prudent decision regarding survival and symptom relief.

Etiology

The cause of aortic stenosis varies in different age groups. For example, senior patients exhibit AS on the grounds of aortic sclerosis, which is characterized by fibrotic and calcified valve leaflets. Stenosis leads to a progressive, degenerative obstruction in this population.

In patients under 70 years of age, most cases are attributed to a congenital bicuspid aortic valve. Other valvular defects such as unicuspid, tricuspid and quadricuspid valves also result in aortic stenosis. In newborns and children under 12 months old, a unicuspid valve results in marked obstruction as well as mortality.

Rheumatic fever is the most common cause of aortic stenosis in all ages in developing countries.

Epidemiology

Calcific or degenerative aortic stenosis, which is more common in males, presents in patients older than 75 years old [1]. It is a gradual process that develops over a decade or more. The prevalence of calcific aortic stenosis in this age group is 2% to 9%. Furthermore, this type usually occurs in predisposed patients with risk factors for atherosclerosis [2]. Aortic sclerosis, which precedes calcific aortic stenosis, also exhibits a frequency that increases with age.

Congenital aortic stenosis, which is usually secondary to unicuspid or bicuspid valves, occurs in 0.33% of live births, with a symptomatic presentation emerging in middle age or later.

Rheumatic aortic stenosis produces symptoms that usually do not manifest until after the sixth decade of life.

Sex distribution
Age distribution

Pathophysiology

The progression of the condition affecting the aortic leaflets involves lipid deposition in addition to inflammatory, calcifying alterations of the valve. This progressive degeneration leads to impairment of the valve's function during the process of systole.

As the valve becomes stenotic, a systolic transvalvular gradient develops between the left ventricle (LV) and the aorta. This results in an outflow obstruction and an increased LV systolic pressure. As compensation for the elevated pressure and the stress on the ventricular wall, the LV undergoes hypertrophy without dilatation of the cavity. Over the years, the heart adapts and alters its physiology. Systolic failure is linked to diminished contractility and decreased cardiac output (CO). Likewise, diastolic failure is associated with an increase in LV end-diastolic pressure and a reduction in CO. These pathophysiologic mechanisms contribute to cardiac failure

It is vital to draw attention to the fact that stenosis progresses slowly. When the left ventricle hypertrophies, it preserves its normal ventricular function and cardiac output for years. However, as illustrated above, systolic function eventually declines in many patients. As for surgical treatment, AVR improves the systolic function unless contractile dysfunction can no longer be reversed [3].

Other cardiac conditions such as aortic regurgitation and mitral regurgitation can synchronously present with aortic stenosis, thereby complicating the process.

Prevention

Reducing risk factors associated with heart disease may prevent aortic stenosis. For example, healthy dietary intake, weight maintenance, smoking cessation/abstinence and proper medical management are beneficial. Furthermore, hypertension, hypercholesterolemia, diabetes, and obesity should all be addressed to prevent disease or progression of the disease.

Good dental hygiene is also important because bacteria from the oral cavity can enter the bloodstream during invasive dental procedures and worsen heart disease.

Summary

Aortic stenosis (AS), a potentially life-threatening heart disease, is characterized by the obstruction of blood flow across the aortic valve. As the most common valvular disease, it is frequently observed in the senior population, primarily due to degenerative calcification that occurs with the aging process. AS is a progressive disease that develops over 10 to 15 years. In younger patients it is a congenital defect, but symptoms present later in life. This type is caused by bicuspid or unicuspid valves. Another cause of aortic stenosis is rheumatic fever, although this is rare in developed countries.

The disease process is complex. Initially, the outflow obstruction leads to compensatory left ventricular hypertrophy (LVH) to normalize the pressure in the ventricle. Eventually and over the years, the stenosis results in systolic and diastolic dysfunction.

Some patients exhibit no symptoms, while others exhibit syncope, angina and dyspnea precipitated by physical exertion. The faster the progression, the more severe the aortic stenosis. Asymptomatic patients do have a good prognosis, but once symptoms emerge, a higher mortality rate is observed.

Determining the diagnosis depends on the clinical presentation as well as indicated imaging such as echocardiography. The recommended treatment is aortic valvular replacement (AVR) which improves symptoms and survivability.

Patient Information

Aortic stenosis is a disease of the aortic valve, which is the channel that allows blood to flow from the heart to the aorta. In the senile population, the valve can become narrow and, therefore, less blood travels from the heart to the aorta. In younger people, this disease is congenital, which means they are born with it.

In the early stages of aortic stenosis, it will not necessarily cause symptoms, because the heart adapts to the changes. The disease continues to develop slowly over the next decade or so. Eventually, symptoms emerge, and the condition becomes more severe. The main symptoms are fainting during physical activity, chest pain, and shortness of breath. These occur partly because the heart cannot pump adequate blood to meet the required demands.

The doctor will ask about all your symptoms and medical history. Then they will listen to your heart to determine if there are any murmurs. Following this, you will have a heart ultrasound. This is called an echocardiogram, and it will show how narrow the valve is. It also provides further analysis of the heart and its function.

The best treatment for those with symptoms is surgery, called aortic valve replacement in which the defective valve is substituted by a mechanical or prosthetic one. This procedure usually improves the symptoms and survivability of the patient. If it is too risky for a patient, a balloon valvotomy is a good option.

Patients with heart disease should follow up with their doctor closely and address any other health problems such as high blood pressure, high cholesterol, diabetes, and obesity.

References

Article

  1. Townsend, CM, Sabiston, DC. Sabiston textbook of surgery: the biological basis of modern surgical practice. Philadelphia, PA: Elsevier Saunders; 2008: 1841-1844.
  2. Stewart BF, Siscovick D, Lind BK, et al. Clinical factors associated with calcific aortic valve disease: Cardiovascular Health Study. Journal of American College of Cardiology. 1997; 29(3):630–634.
  3. Bonow RO, Carabello BA, Chatterjee K, de Leon AC Jr, Faxon DP, Freed MD,Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM,Shanewise JS; 2006 Writing Committee Members; American College ofCardiology/American Heart Association Task Force. 2008 Focused updateincorporated into the ACC/AHA 2006 guidelines for the management of patients withvalvular heart disease: a report of the American College of Cardiology/AmericanHeart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society forCardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.Circulation. 2008; 7;118(15):e523-661.
  4. Kerstjens-Frederikse WS, Du Marchie Sarvaas GJ, et al. Left ventricular outflow tract obstruction: should cardiac screening be offered to first-degree relatives? Heart. 2011. 97(15):1228-32.
  5. Lancellotti P, Magne J, Donal E, et al. Clinical outcome in asymptomatic severe aortic stenosis insights from the new proposed aortic stenosis grading classification. Journal of American College of Cardiology. 2012. 59(3):235-43.
  6. Rodrigues Tda R, Sternick EB, Moreira Mda C. Epilepsy or syncope? An analysis of 55 consecutive patients with loss of consciousness, convulsions, falls, and no EEG abnormalities. Pacing and Clinical Electrophysiology. 2010; 33(7):804-13.
  7. Bonow RO, Carabello BA, Kanu C, et al. 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 [published correction appears in Circulation. 2007;115(15):e409].
  8. Laissy JP, Messika-zeitoun D, Serfaty JM et-al. Comprehensive evaluation of preoperative patients with aortic valve stenosis: usefulness of cardiac multidetector computed tomography. Heart. 2007;93(9): 1121-5.
  9. Chan KL, Teo K, Dumesnil JG, Ni A, Tam J; ASTRONOMER Investigators. Effect of Lipid lowering with rosuvastatin on progression of aortic stenosis: results of the aortic stenosis progression observation: measuring effects of rosuvastatin (ASTRONOMER) trial. Circulation. 2010;121(2):306-14.
  10. Nishimura RA, Carabello BA, Faxon DP, et al. 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. Journal of the American College of Cardiology. 2008. 52(8):676-85

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Last updated: 2018-06-22 01:24