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Aortic valve stenosis is a condition in which the valve between the lower left chamber of the heart and the aorta, the main artery carrying oxygenated blood to the body, cannot open fully and restricts blood flow. This mechanical narrowing causes the heart to work at a much higher pressure than normal in order to pump a sufficient amount of blood to vital organs and tissues. This physical obstruction at the heart’s main outlet directly disrupts the natural dynamics of the circulatory system. For a healthy life, this valve must open and close perfectly with every heartbeat; otherwise, the increased workload may gradually lead to fatigue of the heart and impaired blood circulation.
| Definition | It is a heart valve disease characterized by the inability of blood to pass sufficiently from the heart to the body as a result of narrowing of the aortic valve located between the left ventricle and the aorta. |
| Affected Area | The aortic valve, left ventricle, and over time the entire circulatory system. |
| Primary Function | The aortic valve normally allows blood leaving the heart to pass in one direction into the aorta and prevents blood from flowing backward. |
| Prevalence | It is especially common in advanced age. It is one of the most common heart valve diseases. |
| Risk Factors | Advanced age, congenital bicuspid aortic valve, rheumatic heart disease, high blood pressure, high cholesterol, diabetes, chronic kidney disease, smoking, and atherosclerosis. |
| Causes | Age-related valve calcification, congenital valve anomalies, valve damage developing after rheumatic fever, and more rarely valve diseases related to radiotherapy. |
| Symptoms | Shortness of breath, chest pain (angina), fainting or feeling faint, easy fatigue, decreased exercise capacity, palpitations, and symptoms of heart failure in advanced stages. |
| Early-Stage Findings | Shortness of breath during mild exertion, easy fatigue, and sometimes no symptoms. |
| Advanced-Stage Findings | Shortness of breath at rest, frequent fainting, severe chest pain, swelling in the legs, and development of heart failure. |
| Diagnostic Methods | Detection of a murmur during physical examination, echocardiography (the most important diagnostic method), electrocardiography (ECG), chest X-ray, exercise testing in suitable patients, computed tomography, and cardiac catheterization when necessary. |
| Importance of Echocardiography | It evaluates the valve opening, the speed of blood flow through the valve, the pressure gradient, and the pumping strength of the heart in detail. |
| Severity of the Disease | It is classified as mild, moderate, and severe aortic stenosis. The treatment plan is determined according to this classification. |
| Treatment Approach | Regular follow-up is used in mild asymptomatic cases; valve replacement is the primary treatment in severe or symptomatic patients. |
| Medication Treatment | It does not eliminate the disease but may help control accompanying conditions such as heart failure, hypertension, or rhythm disorders. |
| Surgical Treatment | Replacement of the aortic valve with a mechanical or biological prosthetic valve through open-heart surgery may be performed. |
| TAVI (Transcatheter Aortic Valve Implantation) | It is an interventional treatment method in which a new valve is placed through the groin in patients at high risk for open surgery or in appropriately selected patients. |
| Follow-Up After Treatment | It requires regular cardiology checkups, echocardiographic evaluations, regular use of medications, and compliance with lifestyle recommendations. |
| Possible Complications | Heart failure, rhythm disorders, sudden cardiac death, infective endocarditis, pulmonary edema, and exercise intolerance. |
| Lifestyle Recommendations | Quitting smoking, controlling blood pressure and cholesterol, healthy nutrition, appropriate physical activity, following physician recommendations, and regular follow-up. |
| Exercise | Patients with mild disease may exercise with physician approval. Intense physical activity is not recommended in patients with severe and symptomatic disease. |
| Nutrition | A heart-healthy diet, restriction of salt intake when necessary, and a diet rich in vegetables and fruit and low in saturated fat are recommended. |
| Prevention | Although congenital causes cannot be prevented, control of cardiovascular risk factors, appropriate treatment of rheumatic fever, and regular health checkups may reduce the risk of disease. |
| When Should Emergency Care Be Sought? | Emergency medical evaluation is required in cases of severe chest pain, sudden shortness of breath, fainting, loss of consciousness, or rapidly worsening symptoms of heart failure. |
| Prognosis | It may remain stable for a long time before symptoms develop. However, if untreated after symptoms begin in severe stenosis, life expectancy decreases significantly. Early diagnosis and appropriate valve treatment greatly improve prognosis. |
What Is Aortic Valve Stenosis?
In a healthy heart, the aortic valve opens fully every time the heart contracts, allowing blood to be pumped rapidly and smoothly throughout the body. The inability of the valve to open completely because of calcification or thickening of the valve tissue creates the condition called aortic valve stenosis. The heart muscle, which is responsible for sending blood to every cell in the body, begins to struggle increasingly against a narrowed system. The increased internal pressure first forces the heart muscle to alter its own structure, and as the process progresses, this condition develops into a more general health problem that negatively affects the entire circulation.
How Does the Aging Process Affect the Development of Aortic Valve Stenosis?
As the human body ages, certain cellular changes occur in the heart valves just as they do in many other tissues. The aortic valve is exposed to considerable mechanical stress by opening and closing hundreds of thousands of times every day throughout life. Over the years, fat cells and cholesterol begin to accumulate in the valve leaflets. As a result of the inflammatory response of the body to this accumulation, layers of calcium, in other words calcification, gradually form on the valve tissue. This biological process, which resembles atherosclerosis, disrupts the thin and flexible structure of the valve and transforms it into rigid, immobile tissue. This calcification, which generally becomes more prominent in advanced age groups, constitutes one of the most common causes of the disease.
Do Congenital Structural Problems Cause Aortic Valve Stenosis?
While the aortic valve of most people consists of three thin leaflets, some individuals are born with a valve that has only two leaflets from the developmental period in the womb. This structural difference generally performs its function without causing a problem during youth and adulthood. However, the mechanical load that should be shared by three leaflets being carried by only two increases the turbulence of blood flow across the valve. Because of this increased wear-and-tear force, the process of calcification and narrowing of the valve begins much earlier than normal. In people with this structural difference, aortic valve stenosis may appear during middle age without waiting until advanced age.
Are Rheumatic Diseases Among the Causes of Aortic Valve Stenosis?
Acute rheumatic fever, which develops after throat infections experienced during childhood and generally not treated adequately, may leave permanent scars on the heart valves. The immune system mistakenly reacting to heart tissues while fighting bacteria initiates a silent process of damage lasting for years. The leaflets of the aortic valve may adhere to one another, fuse at the edges, and undergo extensive contraction of the tissue during this process. This rheumatic condition, which generally occurs simultaneously with involvement of other valves in the heart, constitutes another important cause of valve stenosis encountered in young and middle-aged adults.
Why Does the Heart Muscle Thicken as Aortic Valve Stenosis Progresses?
Propelling blood forward through a narrowed valve requires great effort. The main pump of the heart begins to thicken like a muscle that regularly lifts weights in order to overcome this increased resistance and provide sufficient blood to the body. At first, this thickening is a protective adaptation mechanism that enables the heart to perform its function. The heart muscle with thickened walls forces blood strongly through the narrowed valve. However, over time, this thickened tissue loses its flexibility, becomes difficult to relax, and prevents blood from filling the heart comfortably. This causes the adaptation process to eventually evolve into one that tires and weakens the heart.
What Are the Symptoms of Aortic Valve Stenosis?
Although the disease may progress silently for many years, the main complaints experienced in daily life when the stenosis reaches a certain severity are as follows:
- Chest pain
- Shortness of breath
- Dizziness
- Fainting
- Palpitations
- Easy fatigue
- Swelling in the feet
What Are the Risk Factors That Accelerate Aortic Valve Stenosis?
In addition to advancing age, the main factors that increase valve wear and calcification are as follows:
- Advanced age
- High blood pressure
- High cholesterol
- Diabetes
- Smoking
- Obesity
- Kidney failure
Why Does Chest Pain Occur During the Course of Aortic Valve Stenosis?
The oxygen requirement of the heart muscle, which thickens and expends more effort because of narrowing of the aortic valve, increases significantly. In contrast, the blood pressure reaching the coronary arteries that supply the heart remains relatively low because the valve is narrow. During activities requiring exertion, such as walking uphill or walking briskly, the increased oxygen demand of the heart can no longer be met by the limited blood flow provided by the vessels. This imbalance between supply and demand causes pain in the form of pressure, burning, or tightness in the chest. When the patient rests, the workload of the heart decreases, so this pain usually becomes milder or disappears.
How Is Shortness of Breath Related to Aortic Valve Stenosis?
When the heart muscle thickens and stiffens, blood cannot fill the heart comfortably and begins to pool backward in the pulmonary vessels. This increase in pressure causes additional fluid to accumulate around the air sacs in the lungs. When the person exerts themselves, the increased blood flow raises this pressure in the lungs even further, making breathing more difficult. As the disease progresses, this problem may occur not only while walking but even while lying flat at night, causing the person to wake from sleep with air hunger. This is an important sign showing how closely the circulatory and respiratory systems work together.
Why Are Dizziness and Fainting Important in Aortic Valve Stenosis?
While the body is active, the vessels dilate so that more blood can reach the muscles, and the heart must respond to this dilation by pumping more blood. However, in a heart with a narrowed valve, the heart cannot sufficiently increase the amount of blood it ejects no matter how hard it works because the “exit door” is closed. When the vessels dilate but sufficient blood does not arrive, systemic blood pressure suddenly falls. Even a reduction in oxygenated blood reaching the brain for a few seconds may cause vision to darken, severe dizziness, or sudden collapse and fainting. This symptom is an extremely serious warning indicating that the disease has reached a critical point.
How Is Aortic Valve Stenosis Diagnosed with Echocardiography?
A distinct and intense murmur heard in the heart with a stethoscope during physical examination provides the first clue to diagnosis. The primary tool used to confirm this suspicion is echocardiography. This ultrasonography method, which uses sound waves and contains no radiation, displays the internal chambers of the heart and the movement of the valves live on a screen. The intensity of calcification in the valve, restriction of leaflet movement, and the speed of blood passing through the narrowed area are measured precisely with this method. Echocardiography provides physicians with a detailed view of the extent of the valve problem and forms the main roadmap for treatment planning.
According to Which Echocardiographic Criteria Is the Severity of Aortic Valve Stenosis Determined?
The parameters examined in measurements performed with an ultrasound device in order to determine the stage of the disease are as follows:
- Valve area
- Blood flow velocity
- Pressure gradient
- Heart muscle thickness
- Heart pumping strength
- Calcification density
How Is Hidden Aortic Valve Stenosis Detected with a Pharmacological Stress Test?
Sometimes the pumping strength of the heart becomes so weak that there is not enough propulsive force to move blood through the valve. In this situation, the speed of blood passing through the valve is measured as low, and it cannot be determined whether the problem originates from a truly narrowed valve or from a weak heart. To eliminate this uncertainty, a medication that temporarily increases the contractile strength of the heart is administered intravenously while ultrasound is performed simultaneously. If the valve still does not open even though the heart becomes more active, it becomes clear that severe stenosis is the underlying problem. This method is extremely helpful in detecting hidden severe cases.
Do Medications Work in the Treatment of Aortic Valve Stenosis?
Because the calcium deposits and physical adhesions that accumulate on the heart valve create a mechanical obstruction, there is no medication that can dissolve them or restore the valve to its former flexibility. Prescribed medications are used to regulate high blood pressure, remove excess fluid accumulated in the lungs, and balance the heart rhythm rather than treating the valve itself. These medical treatments, which relieve the patient’s complaints in daily life, do not eliminate the underlying problem. Overcoming the obstruction created by a narrowed and hardened valve requires physically opening that valve or replacing it with a new one.
What Is Considered When Making a Treatment Decision for Aortic Valve Stenosis?
The characteristics meticulously evaluated by a council of specialists in order to select the most appropriate method for the patient are as follows:
- Patient age
- General health status
- Vascular anatomy
- Valve structure
- Lung capacity
- Kidney functions
- Accompanying diseases
When Is Open-Heart Surgery Performed in the Treatment of Aortic Valve Stenosis?
The traditional method used for many years for valve replacement involves surgically opening the chest, stopping the heart, removing the damaged valve, and sewing a new one in its place. This method is largely preferred especially in younger patients, in those who simultaneously require different surgical interventions such as treatment of enlargement of the aorta, or in individuals whose vascular routes are too calcified to allow advancement from the groin. The surgical team and heart team examine the patient’s overall condition, review the expected benefits of open surgery, and establish a safe course of treatment.
What Is TAVI, a Non-Surgical Method for Aortic Valve Stenosis?
Transcatheter aortic valve implantation, known as TAVI, is a highly innovative intravascular treatment method that allows valve replacement without the need for open surgery. It is performed without cutting the breastbone, generally by reaching the heart through thin, long tubes called catheters inserted through the artery in the groin. A new biological valve obtained from animal tissues is folded inside a special metal frame called a stent and placed at the tip of this system. When it reaches the heart, the new valve opens and firmly anchors inside the old calcified valve, instantly relieving the obstruction and helping the heart function normally.
What Preparations Are Made Before the TAVI Procedure for Aortic Valve Stenosis?
The preparations performed to increase the safety of the procedure and determine the dimensions of the valve to be used with millimetric precision are as follows:
- Computed tomography
- Vascular mapping
- Valve measurement
- Blood tests
- Rhythm analysis
- Kidney function assessment
How Is the TAVI Procedure Applied Step by Step in Patients with Aortic Valve Stenosis?
The procedure is performed in the angiography laboratory. The physician creates a small entry point in the femoral artery and advances a flexible catheter along the aorta. With the help of advanced X-ray screens called fluoroscopy, the new valve is aligned precisely in the center of the old narrowed valve in the heart. Once the position is confirmed and everything is ready, the valve is deployed either by opening on its own or by being expanded with the help of a balloon inside it. The leaflets of the new valve begin working immediately. All delivery systems are then removed from the vessel, and the entry point in the groin is closed with a small suture.
How Does the Anesthesia Process Work During TAVI for Aortic Valve Stenosis?
Although such major procedures required general anesthesia in the past, lighter anesthesia techniques known as sedation have become widespread with the development of the TAVI method. The patient is relaxed by administering sedative and pain-relieving medications. During this process, the patient remains in a sleep-like state but does not need to be connected to a ventilator. Patients who continue breathing on their own recover much more quickly when the procedure is completed. Of course, because the general health status of every individual is different, the safest anesthesia method is determined together with anesthesia specialists.
Why Is a Pacemaker Used During an Aortic Valve Stenosis Procedure?
For the new valve to be positioned fully and correctly inside the old valve, it is necessary to momentarily stop the pumping action of the heart. If the heart continues to eject blood forcefully at that moment, it may be difficult for the valve to settle into the correct position. To achieve this, a temporary pacing wire is advanced into the patient’s heart. For only ten or fifteen seconds, the heart rhythm is accelerated significantly with the help of the pacemaker. The heart beats so rapidly that it cannot find time to pump blood, and the blood pressure falls. During this brief moment of reduced pumping, the valve is safely positioned, and when the pacemaker is stopped, the heart returns to its normal strong beats.
What Is the Purpose of the Balloon Procedure in the Treatment of Aortic Valve Stenosis?
In some cases, the calcification level of the old valve is so severe that preliminary preparation may be required to allow the new valve to pass through. For this purpose, a deflated balloon at the tip of the catheter is placed inside the narrowed valve and inflated to crack the calcified tissue to some extent. However, because these calcified valves are extremely rigid in adults, dilation performed only with a balloon does not provide a permanent solution. The valve tends to narrow again within months. Therefore, the balloon procedure is used as a step toward TAVI or as a method to temporarily relieve the patient rather than as a definitive standalone treatment.
What Are the Advantages of Transcatheter Methods over Surgery in the Treatment of Aortic Valve Stenosis?
The main positive aspects of these modern techniques, which are performed without opening the chest or causing major surgical trauma to the heart, are as follows:
- No incision
- Reduced bleeding
- Less pain
- Short hospital stay
- Rapid recovery
- Early discharge
How Is Hospital Care Provided After an Aortic Valve Stenosis Procedure?
After the procedure is completed, patients are taken to a coronary intensive care unit or special monitoring units as a precaution. Heart rhythm, blood pressure, and the entry site in the groin are monitored regularly. Because the intervention is performed with a minimally invasive method, patients are generally allowed to get up and begin walking after resting in bed for several hours. If no rhythm disorder or wound-site problem is observed, patients are transferred to the regular ward and spend the following day more actively. The process generally progresses quite rapidly, and most individuals leave the hospital in good health within a few days.
What Awaits Patients with Aortic Valve Stenosis During the Return Home?
The points that people who return home after treatment and begin living with their new valve should pay attention to are as follows:
- Medication regimen
- Short walks
- Physician checkups
- Groin-area care
- Healthy nutrition
- Avoiding heavy lifting
Why Is Regular Follow-Up Important for Aortic Valve Stenosis After Interventional Treatments?
Replacing the diseased valve with a new one removes the enormous burden on the heart and largely eliminates complaints such as shortness of breath and fatigue. However, this new beginning does not mean that medical follow-up has ended. It is very important to monitor the function and position of the new valve and overall heart health once a year with echocardiography. In addition, blood-thinning or blood pressure-regulating medications recommended by the physician should not be interrupted in order to support the healthy function of the valve.
Frequently Asked Questions
Prof. Dr. Kadriye Orta Kılıçkesmez is one of the leading figures in the field of Turkish cardiology. She was born on January 24, 1974, in Tekirdağ. After completing her undergraduate education at Istanbul University Cerrahpaşa Faculty of Medicine, she chose cardiology as her specialty and received her specialist training at the Cardiology Institute of the same university. In 2015, she was appointed by the university to establish the Şişli Etfal cardiology clinic and Angio laboratory. Becoming a professor in 2017, Kadriye Kılıçkesmez established the cardiology clinic and Angio laboratory of Prof. Dr. Cemil Taşçı Hospital in 2020 and ensured that the clinic became a training clinic.
