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Update on the management of aortic stenosis Volume 3, issue 4, Juillet-Août 2007

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Valvular aortic stenosis (AS) is currently the most frequent cardiac valve disease in western countries. In 90 % of cases, the origin is calcific degeneration of a three-leaflet valve or a bicuspid valve. In patients aged > 65 years old, the prevalence of severe AS is 2-3 %, most of them evolving towards a surgical indication. Doppler echocardiography is currently the gold standard for the assessment of hemodynamic severity of AS and its consequences on left ventricular function; it is also the cornerstone of the patient’s management. Accepted criteria for hemodynamic severity are: peak transaortic velocity > 4.0 m/s, mean pressure gradient > 40 mmHg and aortic valve area < 1.0 cm 2 (indexed valve area < 0.6 cm 2/m 2). Surgical valve replacement is the only effective treatment, indicated in cases of severe symptomatic AS. The decision to operate asymptomatic patients with severe AS remains a source of debate. Therefore, new parameters are currently under validation in order to stratify the risk in the asymptomatic patients, including Stress hemodynamics, CT imaging and natriuretic peptides. In the setting of low-gradient AS with severe LV dysfunction, surgery remains largely indicated. Dobutamine hemodynamics in this setting have the potential to assess the real severity of AS and to stratify the operative risk. In the near future, the development of percutaneous aortic valve implantation may offer an alternative strategy in order to treat patients who are at high surgical risk.