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Natural history of asymptomatic aortic stenosis in adults

INTRODUCTION

In individuals with normal aortic valves, the effective area of valve opening equals the cross-sectional area of the left ventricular outflow tract, which is about 3.0 to 4.0 cm2 in adults. As aortic stenosis develops, a minimal valve gradient is present until the orifice area becomes less than one-half normal. The natural history of aortic stenosis therefore begins with a prolonged asymptomatic period associated with minimal mortality.

Serial hemodynamic examinations over periods ranging from two to nine years reveal significant and initially silent progression in most but not all patients. This progression is manifested by a reduction in the aortic valve area and an increase in the transvalvular systolic pressure gradient. The development of symptoms is an indication for valve replacement since the prognosis in untreated symptomatic patients is poor (graph 1) [1,2].

The natural history and rate of progression of asymptomatic aortic stenosis in adults will be reviewed here. The pathophysiology and clinical features of aortic stenosis, medical therapy (including issues related to coronary artery bypass graft surgery and noncardiac surgery), and the timing of valve replacement are discussed separately. (See "Pathophysiology and clinical features of valvular aortic stenosis in adults" and "Medical therapy in asymptomatic aortic stenosis in adults" and "Indications for valve replacement in aortic stenosis in adults".)

DEFINITIONS

Estimation of aortic valve area, aortic jet velocity, and transvalvular gradient by echocardiography or, less often, cardiac catheterization has been used to define patients as having mild, moderate, or severe aortic stenosis (table 1). Critical aortic stenosis is said to be present when the calculated effective valve area is less than 0.75 cm2 or the Doppler aortic jet velocity is over 5 m/sec. (See "Aortic valve area in aortic stenosis", section on 'Critical valve area and severity'.)

Some consideration of body size should be included in any estimation of valve area [3]. However, simply normalizing for body surface area can lead to misleading conclusions, especially in obese patients. In general, somewhat lower values should be used in very small patients and somewhat higher values in very large patients.
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