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Treatment of aortic stenosis

Alexey Portnov, medical expert
Last reviewed: 19.11.2021

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Objectives of aortic stenosis:

Preventing sudden death and heart failure.
Relieving the symptoms of the disease and improving the quality of life.

Indications for surgical treatment of aortic stenosis

Class I

PAA is shown to symptomatic patients with severe aortic stenosis (level of evidence B).
PAA is indicated in patients with severe aortic stenosis during aortocoronary shunting (CABG) (level of evidence C).
PAA is indicated in patients with severe aortic stenosis for surgical interventions on the aorta and / or other heart valves (level of evidence C).
PAA is recommended for patients with severe aortic stenosis and left ventricular systolic dysfunction (level of evidence C).

Class IIa

PAC is justified in patients with moderate aortic stenosis in CABG or surgical interventions on the aorta and other heart valves (level of evidence B).

Class IIb

Carrying out PAA is possible in asymptomatic patients with severe aortic stenosis and paradoxical reaction to the load (eg, the onset of symptoms or asymptomatic hypotension) (level of evidence C).
PAK is possible in adults with severe asymptomatic aortic stenosis, if there is a possibility of rapid disease progression (age, calcification and coronary heart disease) or in case of inability to timely conduct PAK when symptoms appear (level of evidence C).
PAA is possible in patients with mild aortic stenosis when performing CABG in the event that there is a possibility of rapid progression of the disease, for example the presence of moderate or severe calcification (level of evidence C).
PAA is possible in asymptomatic patients with critical aortic stenosis (the aortic aperture area is less than 0.6 cm ², the average gradient is more than 60 mm Hg, the flow rate is more than 5.0 m / s) in case the expected lethality is 1, 0% or less (level of evidence C).

Class III

Carrying out PAK to prevent sudden death in asymptomatic patients is useless if there are no signs listed in the classes of recommendations IIa and IIb (level of evidence B).

Predictors of an unfavorable outcome after aortic valve replacement with aortic stenosis:

Elderly age (over 70 years).
Female.
Urgent conduct of surgical intervention.
Cardiac ischemia.
Previous aortocoronary shunting.
Hypertension.
Left ventricular dysfunction (ejection fraction less than 40 or 50%).
Heart failure.
Atrial fibrillation.
Simultaneous replacement or plasticity of the mitral valve.
Renal failure.

Medication for aortic stenosis

Assign to inoperable patients due to concomitant pathology. The choice of conservative tactics in patients with calcified aortic stenosis is very limited:

beta-blockers (with aortic valve aperture area> 0.8 cm ² ) and nitrates (with caution) - with angina pectoris;
digoxin (with ciliary tachyarrhythmia and / or ejection fraction of 25-30% and below);
diuretics (with caution, with CHF);
ACE inhibitors (thorough dose titration).

When there is pulmonary edema, the introduction of sodium nitroprusside is shown to reduce both stagnant phenomena and improve left ventricular function in the intensive care unit. Class III antiarrhythmics are prescribed for atrial fibrillation after ineffective cardioversion to control the frequency of ventricular contractions.