Aortic stenosis: when do you need treatment? 

What is aortic stenosis? 

Your heart has 4 valves which help your blood move in the right direction through your heart. The aortic valve opens to let blood flow to the rest of your body, and closes to stop it from flowing back into your heart.

But as you get older, your aortic valve can become narrowed which stops it from working properly. This is called aortic stenosis.

This means your heart must work harder to pump blood around the body, causing symptoms like: 

• chest pain
• breathlessness
• blackouts
• feeling more tired than usual.

The extra strain on your heart may also stop your heart pumping blood as well as it should.

The risk of aortic stenosis increases as your age. It’s thought that around 1 in 10 people over the age of 75 years have aortic stenosis.

However, some people are born with an aortic valve that cannot open fully. This is a type of congenital heart disease.

How is aortic stenosis diagnosed?

Aortic stenosis can cause an extra, unusual sound in your heartbeat called a heart murmur.

If your GP listens to your chest and hears a heart murmur, they may refer you for an echo (echocardiogram), which is an ultrasound scan of the heart.

If your scan shows any problems with your valves, you may be referred to a cardiology clinic to discuss your management plan and have further tests, such as a coronary angiogram or a cardiac CT scan.

Depending on how severe your aortic stenosis is, your doctors will decide how often they need to follow you up, for example by doing another echo, or whether you need to have a procedure to manage your condition.

How is aortic stenosis treated?

If you have aortic stenosis and you’re experiencing symptoms, you may need a procedure to replace the dysfunctional valve.

This can improve your symptoms by reducing the strain on your heart and help you live longer.

There are 2 ways to replace your aortic valve:

• heart valve surgery
• TAVI (transcatheter aortic valve implantation).

Heart valve surgery

In general, if you are considered low risk for surgery and fit and healthy, you may be offered heart valve surgery as the first line of treatment.

Your aortic valve will be replaced with a biological valve made from animal tissue or a mechanical valve made from metal. Speak to your surgical team about which valve may be best for you.

This will require you to undergo open heart surgery, which usually involves cutting the chest bone to operate on the heart (sternotomy). You will have a general anaesthetic and will usually need to stay in hospital for at least a week afterwards.

Having a mechanical valve is associated with an increased risk of blood clots. You may be given blood-thinning medicine (anticoagulant) to prevent this if a mechanical valve is recommended.

Replacement valves can last a long time. However, they may need to be replaced again in the future.

• Read more about heart valve replacement surgery.

TAVI

TAVI is an alternative treatment for aortic stenosis, which is increasingly offered instead of surgery.

This is a minimally invasive procedure where a replacement valve is delivered to the heart through a blood vessel, most commonly the femoral artery in the groin.

Unlike heart valve surgery, TAVI usually does not require a general anaesthetic. You may be offered local anaesthetic or light sedation. After the procedure, most people can go home from hospital after 1 to 2 days.

TAVI is a less invasive alternative to heart valve surgery according to the evidence reviewed by NICE (National Institute for Health and Care Excellence).

More TAVI procedures are now carried out than surgical valve replacements in the UK.

If you had a previous aortic valve replacement which has become re-narrowed or leaky, you can also have a valve-in-valve TAVI procedure.

This involves putting a new valve inside the first valve replacement.

• Read more about TAVI.

How can we improve outcomes of TAVI?

With increasing use of TAVI, researchers have been looking at ways to help more people feel better and recover well after the procedure.

Advances in TAVI devices, techniques and care after the procedure have all played a role in improving these outcomes.

For example, a study published in Open Heart Journal in 2018 of 782 people undergoing TAVI in Bern University Hospital, Switzerland, found that those treated with a transcatheter heart valve designed after 2014 had a lower risk of it becoming displaced or leaking over the following 30 days compared to those treated with one designed earlier.

Research is also looking at detecting the early impact of aortic stenosis on the heart. This is because, in some cases, people have received treatment late, and their narrowed valve has already put their heart under too much strain.

More TAVI procedures are now carried out than surgical valve replacements.

Being able to recognise this before the heart has been damaged may help to identify people who would benefit from earlier treatment.

We’re carrying out research with BHF funding to look at how changes in the heart caused by aortic stenosis affects outcomes after TAVI.

We’re using new research tools and advanced image analysis techniques to look for early signs of damage on people’s CT scans before they have the TAVI procedure.

In the long term, this research will contribute to the growing evidence base that should help us identify who needs TAVI earlier, even if they do not have symptoms.

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