Aortic stenosis is a heart valve disorder that causes the aortic valve opening to narrow, hindering blood flow out of the heart. The condition makes the heart work much harder, causing damage over time and, if left untreated, can eventually lead to death.

According to the American Heart Association, aortic stenosis is one of the most common and severe heart valve problems. About 29 percent of people 65 years and older have it, and 2 percent to 9 percent of those over 75 have a severe case.

Although it is found most often in older people, about 1 percent to 2 percent of those younger than 65 are diagnosed with aortic stenosis as a result of childhood illnesses or congenital defects.

In a healthy heart, blood flows freely from the left ventricle through the aortic valve to the aorta and sends oxygen-rich blood throughout the body. When the valve becomes stenotic due to calcium buildup, it doesn’t open and close properly, and blood flow is restricted, causing symptoms such as:

• Chest pain


• Rapid, fluttering heartbeat


• Shortness of breath


• Dizziness or lightheadedness


• Difficulty walking short distances


• Swelling in the feet or ankles


• Difficulty sleeping or needing to sleep sitting up

People often dismiss these symptoms as typical signs of aging and don’t mention them during routine doctor visits. Unfortunately, waiting too long for diagnosis and treatment can cause heart damage that can’t be repaired or reversed. Severe aortic stenosis comes with a risk of sudden death, so it’s important to discuss symptoms with a primary care physician who can make a referral to a cardiologist.

The aortic valve is between the left ventricle and the largest artery in the body, the aorta. After the left ventricle fills with blood, oxygen-rich blood is pumped into the aorta, which carries blood to the brain and into the rest of the body.

With aortic stenosis, the valve becomes stiff, and the left ventricle can’t pump enough blood out of the heart and into the aorta. The heart has to work harder to pump enough for the body to receive a sufficient supply of oxygen-rich blood. As the heart works harder, the muscle becomes stretched and can no longer contract properly, eventually leading to heart failure.

Certain conditions, such as scarring or structural changes, can cause the aortic valve opening to become smaller. These changes make the valve more prone to calcium buildup, which can make it stenotic.

The following are conditions that can cause aortic stenosis.

Bicuspid Aortic Valve

A bicuspid aortic valve is the most common congenital heart defect, affecting approximately 1 percent to 2 percent of the population. It is more common in males than females.

A normal aortic valve has three leaflets, but a bicuspid valve only has two. The valve may not grow with the rest of the heart, making it more difficult for blood to pump through the opening. Over time, the restriction and overwork cause the valve to narrow further and become stiff from calcium buildup.

Many people born with a bicuspid aortic valve don’t have symptoms until later in life. These people may find out after having tests for another health problem or when a doctor hears a murmur when listening to the heart and investigates further to find the source.

Rheumatic Heart Disease

Bacterial infections, such as group A streptococcal infections and scarlet or rheumatic fever, trigger an immune response that causes inflammation throughout the body, including the heart. This can result in rheumatic heart disease. The inflammation can damage heart valves, including the aortic valve, and cause the valve to become stenotic over time.

Rheumatic heart disease is uncommon in the United States and more common in developing nations, yet about 300,000 people worldwide die each year from it. Signs of heart valve damage may not appear until years after the infection is resolved, and most people begin to show symptoms as young adults.

Connective Tissue Disorders

People with autoimmune connective tissue disorders often have heart valve problems. Some of these disorders include:

• Marfan’s syndrome


• Systemic lupus erythematosus


• Rheumatoid arthritis


• Systemic sclerosis


• Sjogren’s syndrome

Calcium buildup, also called atherosclerosis, on the aortic valve increases with age, so people over 65 have the highest incidence of aortic stenosis. Risk factors include:

• Older age


• Male sex


• Congenital heart defects (bicuspid aortic valve)


• Chronic kidney disease


• Diabetes


• High cholesterol


• High blood pressure


• Infections that may affect the heart, such as rheumatic fever and infective endocarditis


• Radiation therapy to the chest

After confirming a diagnosis of aortic stenosis, a health care provider will determine the stage of the disease and decide on the most appropriate treatment. The stage of heart valve disease depends on several aspects, including symptoms, disease severity, valve structure, and blood flow through the heart and lungs.

Heart valve disease is categorized into four primary groups:

• Stage A (at risk): There are risk factors for heart valve disease present.


• Stage B (progressive): The valve disease is mild to moderate, with no current symptoms.


• Stage C (asymptomatic severe): The valve disease is severe, but there are no apparent symptoms.


• Stage D (symptomatic severe): Heart valve disease is severe and is causing symptoms.

Several tests can confirm or rule out aortic stenosis and help determine the severity of the disease.

An echocardiogram is the gold standard for diagnosing aortic stenosis and monitoring its progression. It is an ultrasound of the heart that uses sound waves to show detailed images of the heart in motion. It shows how well the valves open and close and if there is any backflow of blood if the valves don’t close tightly. It can also help measure the severity of aortic stenosis and how weakened the heart has become.

There are two types of echocardiogram: transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE). A TTE is noninvasive and reads images taken with an ultrasound probe on the chest. A TEE is more invasive and involves guiding a flexible tube with an ultrasound probe down the throat and into the esophagus to get a closer look at the heart. A TEE usually requires the patient to be sedated and asleep during the procedure.

Other diagnostic tests for aortic valve stenosis include:

• Electrocardiogram (ECG or EKG): An electrocardiogram is a painless test that only lasts a few minutes and measures the heart’s electrical activity. It can determine how fast or slow the heart is beating, detect irregular heart rhythms, and show patterns related to heart disease or problems within the heart chambers.


• Exercise or stress test: These tests involve riding a stationary bike or walking on a treadmill while monitoring the heart. Exercise and stress tests can help identify symptoms of aortic stenosis during physical activity. If a patient cannot exercise, medications that mimic the effect of exercise on the heart can be administered.


• Chest X-ray: A chest X-ray can show the condition of the heart and lungs. It can show an enlarged heart, which often happens with aortic stenosis. A chest X-ray can also show calcium buildup on the aortic valve or an enlarged aorta.


• Cardiac computerized tomography (CT) scan: A cardiac CT scan provides a cross-sectional view of the heart. It can accurately measure the aorta and provide a detailed view of the aortic valve.


• Cardiac magnetic resonance imaging (MRI) scan: A cardiac MRI uses magnetic fields and radio waves to create detailed heart images that can show the size of the aorta and determine the severity of aortic valve stenosis.


• Cardiac catheterization: Although this test isn’t typically used to diagnose aortic stenosis, it can help determine its severity. It can also be done before aortic valve surgery to ensure the coronary arteries (arteries in the heart) are not blocked. During a cardiac catheterization, a thin, flexible catheter is inserted into an artery at the groin or wrist and advanced into the heart. Dye flows through the catheter as X-ray images of the coronary arteries are taken.

Aortic stenosis makes the heart work harder to pump enough blood out of the heart and into the body. Over time, the stress on the heart can lead to other complications, including:

• Heart attack


• Heart failure


• Sudden cardiac death


• Pulmonary hypertension


• Bleeding


• Infective endocarditisis

Treatment for aortic stenosis depends on the severity of the disease. Those who have been diagnosed with aortic stenosis but don’t have symptoms are in what is known as the “watchful-waiting” phase. During this phase, a health care provider or cardiologist will continue to monitor the disease with regular follow-up visits, testing, and medications.

According to the American Academy of Family Physicians, the survival rate for patients with aortic stenosis managed with watchful waiting is similar to those without aortic stenosis. The current guidelines from the American College of Cardiology and the American Heart Association suggest a yearly echocardiogram for patients with severe, asymptomatic aortic stenosis, every one to two years for moderate stenosis, and every three to five years for mild disease.

Once aortic stenosis becomes symptomatic, surgery to repair or replace the valve is necessary to avoid further decline. The average survival rate for people who become symptomatic but don’t have a repair or replacement is only two to three years. Not only does surgical intervention lead to better survival, but it also significantly alleviates the symptoms of severe aortic stenosis.

1. Medications

Milder cases of aortic stenosis without symptoms can be treated with certain medications. Although these can help control symptoms, they won’t stop the stenosis from worsening since it is a progressive disease. Medications a doctor may prescribe for aortic stenosis include:

• Blood thinners (warfarin, apixaban, rivaroxaban, dabigatran)


• Diuretics (furosemide, bumetanide)


• ACE inhibitors (lisinopril, captopril)


• Beta-blockers (metoprolol, carvedilol, atenolol)

2. Surgical Procedures

The decision to replace the aortic valve depends on severity and symptoms, age, overall health, and whether surgery is needed to repair or replace another valve or treat another heart problem. Whether to have the valve replaced with open-heart surgery or through a minimally invasive technique will depend on independent circumstances.

Balloon Valvuloplasty

This is a minimally invasive procedure to repair the aortic valve. In cases of aortic stenosis, surgeons typically prefer to replace the aortic valve rather than repair it since the valve tends to narrow again after the procedure. However, a valvuloplasty can be utilized if a patient is too ill to tolerate surgery and needs symptom relief.

During a balloon valvuloplasty, a long catheter with a balloon at the end is inserted into an artery in the arm or groin and advanced into the heart and to the site of the aortic valve. Once the catheter reaches the valve, the balloon is inflated, the valve opening widens, and the catheter and balloon are removed.

Surgical Aortic Valve Replacement

A surgical aortic valve replacement (SAVR) can be done with open-heart surgery or, in some cases, using a minimally invasive robotic procedure. Open-heart surgery requires an incision in the chest and the breastbone to be opened, also called a sternotomy.

During a minimally invasive robotic procedure, the surgeon will access the heart through a series of smaller incisions without the need to open the chest and use a robot to perform the surgery. Both procedures require stopping the heart and putting the patient on a heart-lung machine, also called a cardiopulmonary bypass machine, that will do the work of the heart and lungs during the surgery. The heart-lung machine adds oxygen to your blood and pumps it back to your body.

During the SAVR, the surgeon will remove the stenotic aortic valve and replace it with a mechanical or a bioprosthetic (tissue) valve. The surgeon will inform patients about the advantages and disadvantages of these valves.

Mechanical valves are artificial valves made of metal or carbon material. The advantages and disadvantages are as follows:

• Advantages: Mechanical valves are highly durable and are generally for younger patients because there is usually no need for repeat surgery due to valve degeneration.


• Disadvantages: There is a risk of blood clots forming with mechanical valves that could travel through the bloodstream and cause a stroke. People with a mechanical replacement valve need to be on a lifelong regimen of a blood thinner called warfarin, which comes with a higher risk of bleeding and the need for regularly scheduled blood work to make sure there isn’t too much or too little of the medication in the bloodstream.

Bioprosthetic (tissue) valves are artificial and are made of cow or pig tissue. There is no difference in the durability between the types of biological valves. Most valves have some artificial parts that give support and make them easier to put into place. The advantages and disadvantages are as follows:

• Advantages: Lifelong blood-thinning medications aren’t necessary with a tissue valve unless a person has atrial fibrillation. Tissue valves are generally a good choice for older people (60 to 70 years) because they should last their lifetime.


• Disadvantages: Although tissue valves are a more attractive alternative to many, people younger than 60 usually require repeat surgery to replace the valve since they generally only last an average of 10 to 15 years.

Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure that replaces a stenotic aortic valve with a tissue valve. During a TAVR, the surgeon makes a small incision in the artery at the groin and guides a thin, flexible tube through the artery and up to the heart with the new valve. Once in place, the new valve is placed inside the diseased valve, pushing the old valve out of the way as it expands and takes over regulating blood flow.

TAVR was initially designed for older patients who could not tolerate open-heart surgery since it is much less invasive and doesn’t require general anesthesia. Most patients leave the hospital the next day with a shorter recovery period. TAVR has also been approved for younger patients but isn’t always recommended since the tissue valve only lasts 10 to 15 years. Still, many patients prefer having a second TAVR rather than an invasive open-heart surgery with a long recovery.

Ross Procedure

The Ross procedure doesn’t use an artificial valve. Instead, it replaces the diseased aortic valve with the patient’s own pulmonary valve and the pulmonary valve with a healthy donor valve.

The pulmonary valve is similar in size and shape to the aortic valve. It doesn’t degenerate as quickly as the aortic valve because it is not under the same high pressure.

The Ross procedure is a highly complex open-heart surgery with many risks and possible complications. It also requires a lengthy recovery. However, many young patients needing an aortic valve replacement will choose the Ross procedure because they won’t need the lifelong blood-thinning medication they would need with a mechanical valve. The replacement pulmonary valve typically needs to be replaced within 15 to 20 years, although some last much longer. When a new valve is necessary, most people choose a TAVR procedure for replacement.

There is growing evidence that optimism, gratitude, and a positive purpose in life can be essential in protecting the heart and increasing longevity. A positive outlook can also help people already living with cardiovascular disease.

Data from the U.S. Health and Retirement study of Americans over the age of 50 with known stable heart disease showed that having positive psychological traits was associated with lower risk of heart attack. These positive traits included:

• Optimism (38 percent lower risk)


• Positive outlook (32 percent lower risk)


• Having a purpose in life (27 percent lower risk)

Some practical ways to cultivate a positive mindset include the following:

• Focus on strengths rather than weaknesses


• Practice gratitude


• Focus on one’s positive qualities


• Practice self-compassion


• Practice self-care


• Shift attention away from negative thoughts


• Be more optimistic


• Practice meditation


• Set meaningful long-term goals

Since aortic stenosis is a progressive disease and often a silent one, and no treatments can reverse heart valve damage, it’s essential to adhere to a healthy lifestyle to take care of this hard-working heart valve.

Research into the dietary intake of vitamin K-1 has shown it could help combat the onset of aortic stenosis. A 2023 study published by the American Heart Association found that participants with a high intake of vitamin K-1-rich food had a lower incidence of aortic stenosis. They also had a lower risk of aortic stenosis with complications. Foods high in vitamin K-1 include:

• Raw or cooked green leafy vegetables like spinach and kale


• Broccoli


• Brussel sprouts


• Cabbage

Some other dietary supplements that can help minimize and manage the risk of heart disease caused by increased levels of cholesterol include:

• Coenzyme Q10


• Omega-3 vitamins from fish oil


• Red yeast rice

One 2022 study determined that taking calcium supplements—whether with or without vitamin D—can worsen the progression of aortic stenosis, increase the need for aortic valve replacement in seniors, and raise mortality risk. Dr. Samir Kapadia, a Cleveland Clinic cardiologist and lead author of the study, said in the press release that people with aortic stenosis who aren’t getting enough calcium from their diet may still need to supplement calcium. Still, they should consult a doctor before starting a calcium supplement regimen.

While preventing aortic stenosis caused by infections or birth defects isn’t possible, the risk of developing it due to modifiable factors can be lowered by adjusting diet, levels of physical activity, and lifestyle.

Diet

A diet high in processed foods and sugar can contribute to aortic stenosis. Replace these with various fresh fruits, vegetables, and lean meats. Omega-3-rich foods like oily fish and flaxseed can help regulate inflammation, though evidence for whether omega-3 supplements benefit the heart is mixed. High blood pressure can also damage heart valves, so limiting foods with high sodium content and cutting down on alcohol can help lower blood pressure.

Exercise

Regular physical activity can maintain healthy blood pressure, control cholesterol, and keep blood sugar at normal levels. The Physical Activity Guidelines for Americans recommend at least 2.5 hours of moderate-intensity exercise, like brisk walking or cycling, per week. Anyone starting an exercise program should consult their doctor first, especially those with an existing heart condition.

Smoking

One in four deaths caused by heart disease can be linked to smoking. However, there is hope for people who quit. A review in the Journal of Thoracic Disease found that people who quit smoking had the same risk for heart disease as nonsmokers within 10 to 15 years.

Stress

Stress can be just as harmful to the heart as smoking. Mindfulness-focused activities like yoga, meditation, and even spending time with loved ones can keep stress in check. These activities can help lower blood pressure, fight insomnia, reduce anxiety and depression, and improve diabetes control.