Diagnosis and treatment
Aortic stenosis
Estenosis aórtica
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Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estenosis aórtica" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2035 "Ancho" => 2925 "Tamanyo" => 538214 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Assessment of aortic stenosis by echocardiography.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A) Heavily calcified aortic valve. Measurement of the left ventricular outflow tract. B) Continuous Doppler through the aortic valve. Measurement of peak velocity, peak gradient, mean gradient and VTI across the aortic valve. C) Pulsed Doppler in the left ventricular outflow tract. Measurement of VTI in the outflow tract. D) Calculation of aortic valve area.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">AVA, aortic valve area; VTI, time-velocity integral.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0020" class="elsevierStylePara elsevierViewall">Calcific aortic stenosis was described by Mönckeberg in 1904 and is currently the most common valvular heart disease.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Valve degeneration and calcification is the most common cause of aortic stenosis in our setting and affects both bicuspid and tricuspid valves. Its prevalence increases with age, affecting approximately 5% of the population over 65 years of age.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It is, therefore, a major health problem whose importance will presumably increase in the coming years as the population ages. Familial analysis suggests the existence of a familial aggregation that contributes to the risk of aortic stenosis.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Valve involvement is a continuous process that goes from valve sclerosis to severe stenosis. Aortic stenosis is not an exclusively age-related problem (25–45% of octogenarians do not have aortic valve calcification) but is the product of an active inflammatory process that in some respects is reminiscent of atherosclerosis, in fact, both entities share risk factors. Once the haemodynamic obstruction that conditions stenosis becomes significant, the heart begins to undergo a series of adaptations to ensure cardiac output despite increased afterload, primarily left ventricular hypertrophy. It is therefore common for patients with severe aortic stenosis to remain asymptomatic for some time. Eventually, due to the progression of stenosis, as well as the pernicious consequences of the heart's adaptive mechanisms, the patient eventually develops symptoms.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The suspected diagnosis of aortic stenosis is eminently clinical, either due to the auscultation of a murmur, the finding of an abnormal electrocardiogram (ECG) or the occurrence of any of the guiding symptoms. The basis of the diagnosis of aortic stenosis is echocardiography, a technique which, as we will see below, allows us to quantify the degree of stenosis and also to assess the impact that the valvular heart disease is having on the rest of the heart. In some patients, other diagnostic tools such as biomarkers, exercise test, cardiac MRI or cardiac computed tomography (CT) may be useful.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Currently, there is no treatment that has been shown to reverse or slow the valve degenerative process, so treatment of the disease consists of valve replacement with a prosthesis.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This procedure can be performed by open surgery or percutaneously by transcatheter aortic valve implantation (TAVI).</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis</span><p id="par0035" class="elsevierStylePara elsevierViewall">The diagnosis of suspected aortic stenosis is clinical. The classic triad of symptoms of aortic stenosis is angina, syncope and dyspnea.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> These symptoms appear with exertion.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The physical examination is very characteristic. The carotid pulse may be diminished and delayed (<span class="elsevierStyleItalic">parvus et tardus</span>) or have the anacrotic notch (anacrotic pulse) increased. In the aortic focus, there is a loud systolic ejection murmur that may radiate to the mesocardium. Radiation to the carotids or mitral focus with a whistling sound (Gallavardin's phenomenon) and effacement of the second sound are suggestive of severe stenosis.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The ECG may be strictly normal, show signs of left ventricular hypertrophy or a bundle branch block; some patients may have atrial fibrillation.</p><p id="par0050" class="elsevierStylePara elsevierViewall">If aortic stenosis is suspected, the diagnostic test of choice is echocardiography (ECHO).</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Echocardiogram in aortic stenosis</span><p id="par0055" class="elsevierStylePara elsevierViewall">The transthoracic echocardiogram (TTE) allows us to assess the valve anatomy, the degree of morphological involvement and perform a functional study of the severity of the stenosis. It also helps us to assess the impact that the valvular heart disease is having on the left ventricle, as well as to identify cardiac lesions at other levels. The aortic valve may be tricuspid or bicuspid. Morphological involvement in degenerative aortic stenosis consists of thickening, fibrosis and leaflet calcification, often extending into the myocardium and mitral-aortic continuity. Morphological involvement of the valve without functional involvement, i.e., without stenosis, defines aortic sclerosis. This entity is associated with a higher number of cardiovascular risk factors and worse long-term cardiovascular prognosis. It is not uncommon for patients with aortic stenosis to have associated calcification of the mitral annulus with or without accompanying mitral valvular heart disease. Aortic stenosis of rheumatic origin is less common in our setting; in this case the most prevalent lesion will be commissural fusion that conditions a restriction to the opening of the leaflets and is often associated with concomitant mitral valve involvement.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Quantitative assessment of the stenosis severity is performed by Doppler study of blood flow through the aortic valve. There are several parameters that allow us to stratify the degree of stenosis (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The two main values are the mean gradient and the aortic valve area (AVA). As a general rule, stenosis is considered severe when the mean gradient is greater than 40 mmHg and the AVA is less than 1 cm<span class="elsevierStyleSup">2</span>. The correlation between these two parameters is not completely linear, and it is not uncommon to obtain discrepant results between these two measurements. The most common cause of discrepancies between the severity of the different parameters is an error in one of the measurements, so the echocardiographer must ensure that all data have been measured accurately. Patients with low body surface area may also have areas below 1 cm<span class="elsevierStyleSup">2</span> with not very high gradients. Therefore, a good echocardiographic report should always provide a conclusion regarding stenosis severity (mild, moderate or severe) and integrate the anatomical involvement with the different values obtained by Doppler study.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a><a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows how the severity of aortic stenosis is assessed by ECHO. In addition to the anatomical and functional assessment of the aortic valve, the ECHO will provide information on the impact of the valvular heart disease on the left heart (left atrial dilatation and left ventricular hypertrophy), ventricular function, the presence of other valvular heart diseases and the existence or not of pulmonary hypertension.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Diagnosis in doubtful situations</span><p id="par0065" class="elsevierStylePara elsevierViewall">Occasionally, there are discrepancies between the clinical signs and the conventional TTE. A common scenario is the presence of low velocity flow across the aortic valve. The main determinant of the transvalvular gradient is the flow across the aortic valve, so in cases where left ventricular outflow is decreased, the transvalvular gradient will also be decreased. Typically, these patients have low flow (defined as a stroke volume index <35 mL/m<span class="elsevierStyleSup">2</span>), a mean gradient of less than 40 mmHg and an AVA of less than 1 cm<span class="elsevierStyleSup">2</span>. This phenomenon is called "low flow-low gradient" aortic stenosis and there are two main subtypes: the classical form and the paradoxical form.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In the classical form, the "low flow" is determined by impaired ventricular function; in these cases, dobutamine stress ECHO may be useful to determine the true degree of aortic stenosis.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Low-dose dobutamine increases ejection fraction in patients with contractile reserve, increases flow across the aortic valve and, in parallel, increases the transvalvular gradient when aortic stenosis is truly severe. In the paradoxical form, the "low flow" is usually secondary to a small ventricular volume; these are usually women with a very hypertrophic ventricle and significantly impaired relaxation. In these cases, assessment of the true degree of stenosis can be complex. Quantification of aortic valve calcium measured by multidetector CT with electrocardiographic gating has been shown to correlate with the degree of aortic stenosis and may help determine stenosis severity in these situations. Based on studies, aortic stenosis is most likely severe if the aortic valve calcium score is greater than or equal to 2000 in men and 1200 in women. With aortic calcium values below 1600 in men and 800 in women, the likelihood of severe aortic stenosis is very low.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The main problem with this method is that only high or low calcification rates ensure or rule out severity, and there is a grey area where this method is inconclusive.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Finally, sometimes the acoustic window is deficient or does not allow the continuous Doppler to be correctly aligned. This happens in obese patients, with concomitant respiratory disease or in cases where the anatomy is distorted and the position of the heart or the aorta within the thorax is not the usual one. Apart from the apical five-chamber view, the high right parasternal view should be used as it is better aligned with the transaortic flow. If an adequate gradient is still not obtained, aortic valve calcium quantification by CT or anatomical assessment of the aortic valve by transoesophageal echocardiography (TEE) can be used.</p><p id="par0075" class="elsevierStylePara elsevierViewall">Invasive quantification of the degree of stenosis by catheterisation is very accurate and when, exceptionally, diagnostic doubts persist, this method can be used.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Treatment</span><p id="par0080" class="elsevierStylePara elsevierViewall">Treatment of aortic stenosis will usually depend on the degree of stenosis and the presence of symptoms. There is currently no drug treatment that has been shown to reverse or slow the process of valve degeneration, so the only treatment available is valve replacement.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> For this reason, patients with mild to moderate aortic stenosis do not receive any specific treatment for valvular heart disease and are only followed clinically and with regular ECHO.</p><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Identifying the timing of valve replacement</span><p id="par0085" class="elsevierStylePara elsevierViewall">Patients with severe aortic stenosis have a good prognosis when they are asymptomatic; however, the onset of symptoms is a turning point in the natural history of the disease and the prognosis worsens significantly, especially if the patient develops frank heart failure or syncope on exertion.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6</span></a> For this reason, both the American and European consensus guidelines on the treatment of valvular heart disease recommend valve replacement in all symptomatic patients with an IB level of evidence.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,13</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Assessing the symptomatic status of a patient with aortic stenosis is sometimes a challenge. On the one hand, aortic stenosis is an insidious and slow-developing process, so symptoms often go unnoticed as patients gradually limit their physical activity. On the other hand, they are usually older patients with associated comorbidities, so some of the symptoms, mainly dyspnoea, may be multifactorial and not attributable to aortic stenosis. In these cases, a stress test<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> and BNP measurement<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> may be useful.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The indication for valve replacement in asymptomatic patients is controversial. The main risks to a patient with severe aortic stenosis who is asymptomatic are progressive overload of the heart due to a sustained increase in afterload, the possibility of sudden severe symptoms, and sudden death, which in this population has an incidence of 1% per year.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Some authors now favour early intervention when patients are asymptomatic to reduce these risks. However, surgery also carries risks; in addition to perioperative mortality, it is associated with long-term complications such as thrombosis of the prosthesis and a higher incidence of infective endocarditis. In addition, patients with a mechanical prosthesis will require lifelong anticoagulation, with the risks associated with this treatment.</p><p id="par0105" class="elsevierStylePara elsevierViewall">At present, there is insufficient scientific evidence to recommend aortic valve replacement in all asymptomatic patients. The European Society of Cardiology (ESC) recommends valve replacement in asymptomatic patients who have impaired ejection fraction (<55%), an abnormal stress test (development of symptoms and/or blood pressure drop of more than 20 mmHg) and in those patients who are at low surgical risk and also have a very severe degree of stenosis (mean gradient ≥60 mmHg, peak velocity >5 m/s), rapid disease progression on serial ultrasound or persistent elevation of BNP with no other apparent explanation. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> lists the main indications for aortic valve replacement according to the ESC guidelines.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Asymptomatic severe aortic stenosis is currently a very active field of research. Research focuses on one hand on detecting poor prognostic factors in asymptomatic patients with severe aortic stenosis. Several advanced imaging techniques have been shown to identify patients with an increased risk of complications.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Thus, myocardial deformation analysis by ECHO (speckle tracking) is able to identify an early-stage deterioration of ventricular function before ejection fraction is reduced.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Cardiac magnetic resonance imaging can assess the degree of myocardial fibrosis and determine whether it is potentially reversible or whether it is replacement fibrosis that will persist, even if valve replacement is performed.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> An emerging concept is the extent of myocardial damage, which is graded in relation to the involvement of the left ventricle, left atrium, mitral valve, tricuspid valve, pulmonary pressure and right ventricle. This classification has been shown to be associated with prognosis in asymptomatic patients with severe aortic stenosis assessed by both ECHO<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and MRI.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Several randomised clinical trials in asymptomatic patients are underway to compare early valve replacement versus current treatment (periodic monitoring and replacement when symptoms occur, or ejection fraction deteriorates).<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Evidence from these trials is still scarce. Only two studies have been published randomising a total of 302 patients.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22,23</span></a> Both studies have demonstrated the benefit of early intervention, however, they have been justifiably criticised as they included highly selected cases, not representative of the real aortic stenosis population, and surgical mortality was exceptionally low. These studies have been conducted with surgery in patients at low surgical risk, so there is currently no scientific evidence to support transcatheter implantation of a prosthesis in asymptomatic patients.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">Finally, recent studies have shown that moderate aortic stenosis is also associated with an elevated risk of adverse cardiovascular events including increased mortality. Patients with moderate aortic stenosis are a heterogeneous group in whom myocardial involvement, concomitant coronary artery disease and other comorbidities have been identified as markers of worse prognosis. There is no scientific evidence on the optimal treatment for patients with moderate aortic stenosis, so the current recommendation is periodic follow-up; however, the first randomised clinical trials are underway to evaluate the efficacy of valve replacement in this group of patients.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Choice of valve replacement method</span><p id="par0125" class="elsevierStylePara elsevierViewall">Valve replacement can be performed by conventional surgery or by TAVI. There are two main groups of prostheses for transcatheter implantation: self-expanding and balloon-expandable prostheses, depending on the technical mechanism by which the prosthesis is deployed, generated by the mechanical characteristics of the prosthesis coating itself when at body temperature in the case of self-expanding prostheses and externally generated by balloon inflation in the case of balloon-expandable prostheses. Each of these groups offers a number of advantages and disadvantages that make it necessary to customise the choice for each patient. It is important to understand the characteristics and complications of both techniques, and to consider the implications of each treatment on the patient's life in order to identify the best option. The main advantage of TAVI is that it is a minimally invasive procedure that can shorten both the hospital stay and the recovery time after surgery. However, TAVI has a higher rate of vascular complications, perivalvular insufficiency and the need for pacemaker implantation. Patients treated with surgery have a higher risk of bleeding, renal failure and development of atrial fibrillation.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The development of TAVI has increased the number of patients who have been able to benefit from valve replacement by offering a therapeutic alternative for patients at very high surgical risk. But far from remaining in this context, the therapy has been extended to an increasing number of patients and has now been shown in randomised trials to be non-inferior to surgery not only in high-risk patients, but also in intermediate- and low-risk patients.<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25–27</span></a> If TAVI has not become widespread as the treatment of choice, especially in young patients, it is because of the possibility of resulting in periprosthetic regurgitation or the need for a pacemaker, the uncertainty about the durability of the prosthesis and the possible interposition of the prosthesis with the coronary ostia. The development of new generation percutaneous prostheses has significantly decreased the degree of periprosthetic regurgitation after TAVI and although this rate is still higher in percutaneous prostheses compared to surgical prostheses, the clinical relevance of this problem is low. To minimise this complication, accurate anatomical assessment with multidetector CT is essential prior to implantation.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> The need for pacemaker implantation after surgery remains high (between 6 and 34% in different series)<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25,27</span></a> and is currently the main obstacle to extending therapy to younger patients. The development of post-procedural left bundle branch block is a predictor of mortality after TAVI and has clear long-term prognostic implications as it increases the risk of heart failure.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> The available evidence on the durability of percutaneous prostheses is still limited. This was not a problem when they were only indicated in elderly patients whose life expectancy was shorter than the expected durability of the prosthesis, but when implanting these devices in younger patients, the possibility of future reintervention due to prosthetic dysfunction must be taken into consideration.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Finally, coronary ostia re-engagement can be complex after percutaneous prosthesis implantation. This issue is relevant when implanting prostheses in young patients because of the possibility of coronary artery disease progression throughout life. To overcome this limitation, techniques that allow alignment of the prosthesis with the coronary arteries<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> have recently been developed and are in the process of validation. At the other end of the patient continuum, given that the disease primarily affects elderly patients with associated multi-pathology, it is important to ensure that the patient will derive clinical benefit from the intervention. Assessment of the patient's cognitive and functional status and comorbidities is essential in the decision-making process and TAVI implantation is currently not indicated for patients in whom the intervention will not result in an expected improvement in quality of life or survival. In this regard, it is advisable to use objective scales when in doubt.</p><p id="par0135" class="elsevierStylePara elsevierViewall">The choice between surgery and TAVI is individualised for each patient, taking into account clinical and anatomical factors, procedure-specific considerations and the patient's own wishes. Cases are presented in a multidisciplinary session ideally involving clinicians, cardiac imaging specialists, cardiac surgeons, interventional cardiologists and post-operative acute care physicians. As a general rule, surgery is most appropriate in young patients with low comorbidity and TAVI in elderly patients with high surgical risk. In all other situations, anatomical considerations, centre experience and patient preferences play a major role in the decision. ESC clinical practice guidelines suggest an age limit below 75 years and a surgical risk below 4% according to the usual scales in order to consider that a patient is a candidate for surgery.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">A general algorithm for the diagnosis and treatment of aortic stenosis is given in <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">Aortic stenosis is a very common condition that mainly affects the elderly. Diagnosis is relatively straightforward and is based on ECHO. Dobutamine stress ECHO and CT assessment of aortic valve calcium may be useful in special situations. The only available treatment is aortic valve replacement, which is indicated when valvular heart disease is severe and symptomatic and may be considered in some asymptomatic patients with high-risk criteria. Clinical assessment of the patient's functional status, symptoms and co-morbidities are essential when indicating valve replacement, which can be performed by conventional surgery or percutaneously. The development of TAVI has made it possible to treat many patients who were not previously considered as candidates for surgery. Due to its less invasive nature, it is increasingly being extended to lower risk patients. However, percutaneous prosthesis still has limitations that prevent its generalised use as the treatment of choice for aortic stenosis, notably the high rate of need for pacemaker implantation after the procedure.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical considerations</span><p id="par0150" class="elsevierStylePara elsevierViewall">As this is a review, it was not necessary to obtain informed consent or the agreement of an ethics committee to carry it out.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Funding</span><p id="par0155" class="elsevierStylePara elsevierViewall">This review has not received any funding.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflict of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:3 [ "identificador" => "sec0010" "titulo" => "Diagnosis" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Echocardiogram in aortic stenosis" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis in doubtful situations" ] ] ] 2 => array:3 [ "identificador" => "sec0025" "titulo" => "Treatment" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0030" "titulo" => "Identifying the timing of valve replacement" ] 1 => array:2 [ "identificador" => "sec0035" "titulo" => "Choice of valve replacement method" ] ] ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusions" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Ethical considerations" ] 5 => array:2 [ "identificador" => "sec0050" "titulo" => "Funding" ] 6 => array:2 [ "identificador" => "sec0055" "titulo" => "Conflict of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-04-15" "fechaAceptado" => "2023-06-27" "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2035 "Ancho" => 2925 "Tamanyo" => 538214 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Assessment of aortic stenosis by echocardiography.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A) Heavily calcified aortic valve. Measurement of the left ventricular outflow tract. B) Continuous Doppler through the aortic valve. Measurement of peak velocity, peak gradient, mean gradient and VTI across the aortic valve. C) Pulsed Doppler in the left ventricular outflow tract. Measurement of VTI in the outflow tract. D) Calculation of aortic valve area.</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">AVA, aortic valve area; VTI, time-velocity integral.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1408 "Ancho" => 2925 "Tamanyo" => 172386 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Diagnosis and treatment of aortic stenosis.</p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">ECG: electrocardiogram; BNP: brain natriuretic peptide or B-type; TAVI: transcatheter aortic valve implantation.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">AVA, aortic valve area; VTI, time-velocity integral. The VTI ratio is the result of dividing the VTI in the left ventricular outflow tract by the VTI in the aortic valve.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Maximum velocity (m/s) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Mean gradient (mmHg) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">AVA (cm<span class="elsevierStyleSup">2</span>) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">VTI Relationship \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sclerosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤2.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Mild stenosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.6−2.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>0.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Moderate stenosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.0−3.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20−39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5−1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.25−0.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Severe stenosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.0−4.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40−59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.9−0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><0.25 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Very severe stenosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥5.0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≥60 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">≤0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3332411.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Assessment of the severity of aortic stenosis based on the main echocardiographic parameters.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">BP: blood pressure; V<span class="elsevierStyleInf">máx</span>: peak velocity across the aortic valve; BNP: brain natriuretic peptide or B-type natriuretic peptide.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Indication \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="center" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Evidence \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Symptomatic patients</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High gradient stenosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IB \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low-flow-low-gradient stenosis with ventricular dysfunction and contractile reserve \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IB \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low-flow-low-gradient stenosis and normal ejection fraction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IIaC \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low-flow-low-gradient stenosis with ventricular dysfunction without contractile reserve \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IIaC \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Asymptomatic patients</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ejection fraction <50%. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IB \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Stress test symptoms \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IB \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ejection fraction ≤55%. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IIaB \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BP drop (<20 mmHg) on stress test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IIaC \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Severe aortic stenosis with ejection fraction >55%, normal stress test, low surgical risk and any of the following criteria: \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IIaB</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0005" class="elsevierStylePara elsevierViewall">Very severe stenosis (mean gradient ≥60 mmHg, V<span class="elsevierStyleInf">máx</span> > 5 m/s)</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0010" class="elsevierStylePara elsevierViewall">Severe valvular calcification and rapid progression of the V<span class="elsevierStyleInf">máx</span> (≥0.3 m/s/year)</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0015" class="elsevierStylePara elsevierViewall">Significant and repeated elevation of BNP (three times the normal value)</p></li></ul> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3332412.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Indications for valve replacement in severe aortic stenosis according to the European Society of Cardiology.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Der normale histologische Bau und die Sklerose der Aortenklappen" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.G. 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