Aortic valve diseases

Aortic stenosis
Aortic stenosis is a narrowing of the valve at the outlet of the left ventricle (the aortic valve). Narrowing of the outflow opening increases the workload of the heart, eventually leading to heart failure if left untreated.

Causes of aortic stenosis
There are three main causes of aortic stenosis:

• Degenerative disease, which is common in older patients. This degeneration is favoured by high blood pressure and possibly by atherosclerosis, but it can also appear at an early age in certain congenital abnormalities of the aortic valves.
• Bicuspid aortic valve, which is present in 1 to 2% of the general population. The structure of the aortic valve (2 cusps instead of 3) accelerates valve ageing; consequently, a bicuspid aortic valve is a more frequent cause of valvular disease in younger people.
• Acute rheumatic fever, which has become rare in Northern Europe thanks to the early administration of antibiotics in children with sore throats.

• Angina pectoris: chest pain that generally occurs during exertion and may also occur in coronary artery disease.
• Exertional syncope.
• Dyspnoea (shortness of breath) occurs later in the course of the disease.

This is the surgery used to remove the obstruction to left ventricular outflow. It generally involves replacing the aortic valve with either a biological or mechanical prosthesis. Less commonly, the valve is replaced with the patient’s pulmonary valve (Ross procedure). Surgery is indicated as soon as symptoms appear.

Valve insufficiency, particularly of the aortic valve in this case, is the inability of the valve to close completely. This results in retrograde leakage (regurgitation) of blood back into the heart chamber from which it originated. In this case, blood ejected from the aorta flows back into the left ventricle, causing it to become “overworked”.

• Acute rheumatic fever has become a rare cause in Europe. In this case, insufficiency is most often accompanied by stenosis (see above). This is then referred to as aortic valve disease.
• Bicuspid aortic valve (a congenital morphological abnormality).
• Infective endocarditis is the most common cause of acquired acute aortic insufficiency.
• Annulo-aortic ectasia: dilation of the aortic root, resulting in dilation of the valve annulus, whose leaflets no longer come into contact.
• Isolated valvular dysplasia, in which the valvular tissue degenerates.
• Dissection of the ascending aorta.
• Aortitis, such as syphilis, Takayasu disease, Kawasaki disease, ankylosing spondylitis, Horton’s disease, Behçet’s disease, etc.
• Connective tissue diseases such as systemic lupus erythematosus, antiphospholipid syndrome, etc.
• Chest trauma (extremely rare).

• Dyspnoea
• Presyncope; syncope is less common.
• Fatigue.

Initially, treatment is medical, with the aim of stabilising the patient and preventing deterioration of cardiac muscle function. If the patient develops symptoms or if the left ventricle deteriorates (on echocardiography), the valve should be replaced with a biological or mechanical prosthesis. In some cases, the valve can be repaired (for example, in annuloaortic ectasia). Acute aortic regurgitation (aortic dissection or endocarditis) most often constitutes a surgical emergency.