What is Aortic Valve Stenosis? Symptoms and Treatment

Aortic stenosis is a condition in which the aortic valve narrows, restricting blood flow from the heart to the aorta and body. This narrowing increases pressure in the left ventricle, leading to thickening of the heart muscle and potentially causing heart failure if untreated. Symptoms of aortic stenosis usually include chest pain, fainting, and shortness of breath during physical activity. The severity of these symptoms depends on the degree of valve narrowing, often progressing slowly over years until noticeable limitations in daily life occur. Causes of aortic stenosis include age-related valve calcification, congenital bicuspid valve, and rheumatic fever. Each of these mechanisms leads to impaired valve mobility and stiffness, resulting in gradual obstruction of blood flow over time. Treatment options range from careful monitoring in mild cases to valve replacement in advanced disease. Surgical or transcatheter aortic valve replacement (TAVR) are the most effective interventions, improving survival and quality of life significantly in symptomatic patients.

Medical Name	Aortic Stenosis (Aortic Valve Stenosis)
Type	Valve disease
Affected System	Cardiovascular system
Causes	Degenerative (age-related calcification), congenital bicuspid aortic valve, rheumatic fever
Symptoms	Chest pain, shortness of breath on exertion, syncope, fatigue, signs of heart failure in advanced cases
Diagnostic Methods	Transthoracic echocardiography (main diagnostic tool), ECG, CT/MR, cardiac catheterization (when necessary)
Treatment Methods	Follow-up in mild cases; surgical valve repair or replacement (AVR) in severe cases
Complications	Left ventricular hypertrophy, heart failure, arrhythmia, sudden cardiac death
Monitoring	Regular ECHO follow-up, referral to surgery according to symptom development and valve opening measurement, control of risk factors

How the Heart Works and What is Aortic Valve Stenosis?

We can think of our heart as a perfect pump with four chambers and four valves that keep blood flowing in the right direction between them. One of the most important of these valves, the aortic valve, is strategically located between the left ventricle, the heart’s most powerful contractile chamber, and the main artery (the aorta), which distributes oxygen-rich blood throughout the body. A healthy aortic valve consists of three thin, flexible and elegant leaflets. Each time our heart contracts, these leaflets open completely and effortlessly, allowing blood to flow powerfully from the heart into the aorta. When the heart relaxes, they close in perfect harmony with each other, preventing blood from escaping back into the heart. This seamless one-way passage system guarantees that all our organs and tissues, from our brain to our toes, receive the oxygenated blood they need. Aortic valve stenosis, or aortic stenosis as it is called in medicine, is a malfunction of this perfect valve mechanism. Over time, the valve leaflets thicken, calcify, harden or stick together. As a result, the valve opening through which blood must pass becomes significantly narrower. The aortic valve becomes unable to open fully, just as a door that has rusted and the hinges have seized cannot open fully. This narrowing restricts the amount of blood pumped from the heart to the body. When the disease progresses, i.e. when severe aortic stenosis becomes established, this restriction can become so severe that the body cannot meet even its basic needs. This is one of the most common and serious valvular heart diseases that can have irreversible effects on the functioning of the heart if left untreated.

How Does Aortic Valve Stenosis Disrupt Heart Functioning?

When aortic valve stenosis develops, the heart becomes like a pump trying to push water from a dam in order to push blood through the narrowed valve. In order to meet the body’s blood demand, the left ventricle of the heart has to create a much higher pressure than normal. This can be likened to a garden hose with a narrower and narrower end; as the flow of water becomes more difficult, the pressure inside the hose increases dangerously. The heart develops a defense mechanism to protect itself against this ever-increasing pressure and load. To cope with this increased workload, the muscle wall of the left ventricle thickens and strengthens over time. Just as the muscles of a weight-training athlete develop, the heart muscle increases in volume (hypertrophy) to cope with this demanding task. This allows the heart to function without interruption for a while and the disease can progress insidiously for years without symptoms. However, this compensation mechanism comes at a cost. On the one hand, thickening heart muscle increases pumping power, but on the other hand it reduces the internal volume of the heart chamber and reduces the heart’s capacity to fill with blood. More importantly, the thickened muscle becomes stiff over time and cannot relax as flexibly as before. After a while, the heart’s compensatory efforts are exhausted. Constantly overworked, stiffened and undernourished, the heart muscle tires and eventually begins to weaken. At this point, the heart’s pumping power (ejection fraction) decreases. The inability of the heart to pump blood forward effectively causes blood to pool backwards, in the lungs. This leads to the classic symptoms of heart failure, such as shortness of breath, extreme fatigue and swelling of the legs, which severely impair the patient’s quality of life.

What Causes the Development of Aortic Valve Stenosis?

Aortic valve stenosis is usually caused by three main causes. Knowing these causes gives us important clues about who may develop the disease and when. The main causes of aortic valve stenosis are:

• Age-related calcification (Degenerative calcification)
• Congenital valve structure disorders (congenital defects)
• Previous rheumatic fever

Age-related calcification: This is the most common cause of aortic stenosis, especially in developed countries and in people over the age of 65. Over the years, calcium mineral in the bloodstream accumulates on the valve leaflets and leads to aortic valve degenerative changes, i.e. calcification. This build-up causes the valves to lose their elasticity, become stiff and have reduced mobility. This process is not simple “wear and tear” but an active disease process involving similar mechanisms to atherosclerosis. Congenital Heart Defects: Some people are born with an anomaly in which the aortic valve, which should normally have three leaflets (tricuspid), develops with two leaflets (bicuspid). This occurs in about 1-2% of the population. The two-leaf valve begins to calcify and narrow much earlier than a three-leaf valve, usually in the 50s or 60s, because it disrupts normal blood flow. Rheumatic Fever Rheumatic fever, a complication of inadequately treated beta germ (streptococcal) throat infections, especially in childhood, can cause permanent damage to the heart valves. This disease causes scar tissue to form on the valve leaflets, causing them to stick together and narrow.

Who is at Risk for Aortic Valve Stenosis?

Some people are more prone to aortic valve stenosis because of their lifestyle or genetic heritage. Risk factors are divided into two main groups: modifiable and non-modifiable. Non-modifiable Risk Factors:

• Advanced Age: Aging is the most important risk factor as it is a process in which valve calcification naturally increases.
• Male Gender: Aortic stenosis, especially the type due to congenital bicuspid aortic valve, is more common in men than in women.
• Congenital Valve Abnormalities: Structural defects present at birth, such as a bicuspid aortic valve, significantly increase the risk.

Modifiable and Medical Risk Factors:

• High Blood Pressure (Hypertension): Increases stress on the heart valves and accelerates the calcification process.
• High Cholesterol (Dyslipidemia): Disrupts the valve structure with mechanisms similar to arteriosclerosis.
• Diabetes (Diabetes): High blood sugar triggers inflammation and calcification in valve tissue.
• Smoking: Increases the risk of calcification by disrupting the vascular structure.
• Chronic Kidney Disease: Calcium and phosphate imbalance in the body accelerates valve calcification.
• Previous Infections: A history of rheumatic fever or infective endocarditis can leave permanent damage to the valves.
• Receiving Radiation Therapy to the Chest: Radiotherapy to the chest, especially for the treatment of cancers such as lymphoma, can lead to hardening and calcification of the valves years later. Controlling these factors is as important for valve health as it is for the treatment of cardiovascular calcification.

What are the Warning Signs of Aortic Valve Stenosis?

Aortic valve stenosis is an insidious disease that can progress asymptomatically for many years. The heart can compensate for the increased workload for a long time. However, as the disease progresses and aortic stenosis becomes more severe, the heart’s compensatory mechanisms begin to struggle and the first symptoms usually appear during physical exertion when the body’s oxygen demand increases. These symptoms indicate that the disease has reached a stage that requires treatment. Early Symptoms: These symptoms are usually mild and may be seen by patients as a natural part of aging, which can delay diagnosis:

• Tired more quickly than usual
• Gasping for breath, especially when climbing stairs or hills
• Decreased overall physical activity capacity

Late and Advanced Symptoms: As the stenosis becomes more serious, the symptoms become more severe and can occur even at rest. This stage requires urgent medical attention. Symptoms of aortic valve stenosis at this stage include

• Feeling of pressure, tightness or pain in the chest (angina)
• Dizziness, blackouts or fainting (syncope)
• Severe shortness of breath when lying flat or waking up at night
• A feeling that the heart beats fast, irregularly or very strongly (palpitations)
• Swelling in the ankles and legs (edema)

What Are the Classic Triple Signs of Advanced Aortic Valve Stenosis?

The appearance of three main symptoms in the course of advanced aortic valve stenosis indicates that the disease has now reached a critical point and is life-threatening. These three symptoms are the alarm that the heart’s compensatory mechanisms are completely exhausted and can no longer meet the body’s basic needs. The presence of these symptoms indicates a much more serious condition than milder conditions such as the symptoms of grade 1 aortic insufficiency. These are the classic three symptoms:

• Chest Pain (Angina): This occurs when the heart muscle, which has thickened and needs more oxygen, does not receive enough oxygen due to insufficient blood flow through the narrowed valve. If the valve is not replaced after the onset of this symptom, life expectancy is reduced to about 5 years.
• Fainting (Syncope): Usually occurs during exertion, when the heart is unable to meet the body’s increased blood demand due to a narrowed valve, resulting in a momentary decrease in blood flow to the brain. When this symptom develops, if left untreated, life expectancy decreases to approximately 3 years.
• Shortness of breath (heart failure): The most serious symptom of the triad. It occurs when the weakened heart is unable to pump blood forward and it pools in the lungs. Once symptoms of heart failure begin, the average life expectancy drops to just 2 years, or even less.

How is Aortic Valve Stenosis Diagnosed?

Aortic valve stenosis is diagnosed by listening to the patient’s complaints, performing a detailed physical examination and then using modern imaging methods. The first suspicion is usually aroused by the typical “murmur” heard when listening to the heart with a stethoscope during a medical examination for another reason. This murmur is the sound of the turbulent flow of blood through the narrowed valve. However, hearing the murmur is only a suspicion and additional tests are needed to confirm the diagnosis. Echocardiography (ECHO) is the most important of these tests. Echocardiography, an ultrasound of the heart, is the gold standard for diagnosing aortic stenosis. This painless and radiation-free test uses sound waves to provide a clear picture of the structure and function of the heart and valves, the severity of the stenosis and how the heart adapts to this condition. ECHO provides the following critical information:

• Details of the cover structure (number of leaflets, thickness, degree of calcification)
• Hemodynamic measurements that determine the severity of the stenosis (blood flow velocity, pressure difference)
• Area of the valve opening (Aortic valve area)
• The pumping power of the heart (ejection fraction) and the thickness of the muscle wall

In most cases, these tests are sufficient for diagnosis. However, in some special cases or for surgical planning, additional tests may be required. For example, patients who are scheduled for surgery and are at risk of coronary artery disease may require coronary angiography to check the heart vessels.

Can Aortic Valve Stenosis be Treated with Medication?

This is one of the most common questions patients ask. Unfortunately, there is no proven drug treatment that can correct, reverse or stop the progression of aortic valve stenosis. The basis of the problem is mechanical, i.e. the physical constriction and calcification of the valves. Therefore, no pill can solve this calcification or widen the narrowed doorway. However, this does not mean that medicines are not used at all. Drug treatment focuses on managing the problems caused by the disease, rather than solving the main problem with the valve. The aim is to relax the patient, reduce the workload on the heart and prepare the patient for the final treatment – valve replacement – in a better condition. Medicines used for this purpose are:

• Diuretics (diuretics), which relieve shortness of breath by removing excess fluid from the body.
• Medicines that control high blood pressure and can reduce chest pain by slowing the heart rate.
• Other supportive medicines that reduce the burden on the heart when heart failure develops.

Which Treatment Methods Are Used in Severe Aortic Valve Stenosis?

The only effective treatment for symptomatic severe aortic stenosis is to remove the diseased valve and replace it with a new prosthetic valve. Today, there are two main modern methods for this procedure: Surgical Aortic Valve Replacement (SAVR) and Transcatheter Aortic Valve Replacement (TAVR). Which method to choose is jointly decided by a “Heart Team” consisting of an interventional cardiologist and a cardiac surgeon, based on the patient’s age, general health status, surgical risk and anatomical features.

• Surgical Aortic Valve Replacement (SAVR):

This is open-heart surgery, which for years has been considered the “gold standard” in the treatment of aortic stenosis. The sternum is opened to access the heart, the patient is temporarily connected to a heart-lung machine and the heart is stopped. The surgeon carefully removes the calcified and dysfunctional aortic valve and replaces it with a mechanical or bioprosthetic (tissue) valve. It is still one of the best options, especially for younger, low surgical risk and long life expectancy patients.

• Transcatheter Aortic Valve Replacement (TAVR):

It is a minimally invasive procedure that has revolutionized the medical world in recent years. In this procedure, the rib cage is not opened. A thin catheter is inserted through an artery, usually in the groin, and the compressed new valve is advanced into the heart. After precise positioning inside the diseased valve, the new valve expands, pushing the old one aside and immediately begins to function. TAVR was developed specifically for patients who are at high risk for open heart surgery, such as the elderly or those with additional serious illnesses. However, with the development of technology and the increase in successful results, it is now safely applied in lower-risk patients.

What is the Importance of Lifestyle Changes in the Treatment of Aortic Valve Stenosis?

Although there is no lifestyle change that will directly stop the progression of aortic valve stenosis, it is extremely important to take certain steps to maintain overall cardiovascular health, reduce the workload on the heart and minimize the risk of complications. Recommendations to Support Heart Health:

• Reduce Salt Consumption: It keeps fluid accumulation in the body and blood pressure under control.
• Avoid Saturated and Trans Fats: Protects vascular health by regulating cholesterol levels.
• Limit Processed Foods: Opt for fresh and natural foods.
• Quit Smoking: It is one of the most harmful habits for the heart and blood vessels.
• Maintain Ideal Weight: Being overweight directly increases the burden the heart has to carry.
• Check Your Activity Level with Your Doctor: Those with mild stenosis can do most activities, while those with severe stenosis may need to avoid heavy and competitive sports.
• Pay Attention to Oral and Dental Hygiene: Gum infections can lead to a serious valve infection called “infective endocarditis”, where bacteria can enter the bloodstream and settle on damaged heart valves. Regular dental check-ups are therefore a must.

What kind of a healing process awaits patients after aortic valve replacement?

Recovery after aortic valve replacement varies significantly depending on the method used (SAVR or TAVR). Recovery after SAVR (Open Heart Surgery): This process is longer and more gradual. Patients are usually admitted to the ward after 1-2 days in intensive care and stay in hospital for about 1 week in total. The most critical period after returning home is the 6-8 weeks needed for the sternum to fuse. During this period, patients are asked to

• lifting no more than 5 kilograms
• Avoiding movements that strain the chest muscles such as pushing and pulling
• Not driving for about 6 weeks
• Regularly performing breathing and walking exercises recommended by physiotherapists

Recovery After TAVR: One of the biggest advantages of TAVR is that it offers a much faster recovery. Patients can usually be up and walking and discharged from hospital within 1-2 days after the procedure. Activity restrictions are much less and most patients can return to normal daily life within a few weeks. After both procedures, it is highly recommended that the patient participate in a cardiac rehabilitation program to safely increase their strength and endurance.

Is Long-Term Care and Follow-up Necessary After Aortic Valve Replacement?

Yes, it is absolutely necessary. Aortic valve replacement is not the end of the treatment process but the new beginning of a healthy life. Regular lifelong follow-up is essential to ensure that the new valve works smoothly for many years and to maintain the patient’s overall heart health. The follow-up protocol is determined by the physician according to the patient’s condition but usually includes

• First month control after the procedure
• First year check
• Followed by regular annual medical examinations and echocardiography (ECHO) checks

Annual ECHO checks are vital to assess the function of the new valve and to detect any signs of wear or leakage at an early stage. It should be kept in mind that the valve may wear out over time, especially in patients with bioprosthetic (tissue) valves. These annual checks catch a potential problem early, allowing a second intervention to be planned in a timely and safe manner if necessary. It should not be forgotten that the long-term success of a successful valve operation is possible with regular and conscious follow-up.

Frequently Asked Questions