Aortic stenosis

Aortic valve stenosis (or aortic stenosis) occurs when the valve between the heart and the aorta is narrowed.

This narrowing prevents the structure from functioning correctly. The disease is manifested by a decrease in blood flow in the aorta and the rest of the body.

If the aortic valve is narrowed, the heart has to work harder to pump the necessary blood to the body.

Depending on the position with respect to the aortic valve, stenosis can:

• supravalvular,
• valvular,
• be subvalvular.

Hypertrophic subaortic stenosis is characterized by asymmetric thickening of the myocardium below the valve. The result is an obstruction of blood flow.

What are the causes of aortic valve stenosis?

The aortic valve opens and closes every time the heart beats. This action happens every second of life. Genetic and predetermined changes in the state of health can prevent the valve from performing its functions correctly.

Congenital
Aortic valve stenosis can be present at birth (congenital). The opening of the flap is formed from three pockets, which, if they work properly, fit together perfectly. Some children are born:

1. without all three pocket flaps,
2. with pockets that are fused together (bicuspid arrangement of the aortic valve),
3. too thick pockets that cannot open and close.

Rheumatic fever
Rheumatic fever is a disease that affects the following structures:

• brain and nerves,
• Joints
• Heart
• Skin.

It can occur in adults and in children with a sore throat. Sore throat is a contagious condition caused by type B streptococcal bacteria.

Valve calcification
Calcium is an important mineral for maintaining bone strength. This element can cause problems if it settles on the aortic valve. Limescale deposits affect the flap pockets and prevent proper functioning.
The stenosis of the valve can cause the blood to flow back into the left ventricle.
This process is called valve insufficiency or regurgitation.
Calcified aortic stenosis is a degenerative disease and represents the majority of cases of aortic stenosis (82%).
The less common diseases are:

• rheumatoid aortic stenosis (11%),
• congenital aortic stenosis (5.6%),
• aortic stenosis caused by endocarditis (1.4%).

In the elderly, the thickening or calcification of cardiac structures affects about 2-7% of the population over 65 years of age.

Some other causes of calcifications of the aortic valve are given by:

• Alcohol consumption
• Smoke
• Hypertension
• Atherosclerosis
• high cholesterol in the blood.

After the therapy of the blood group diet of Dr. D ́Adamo and Mozzi, the calcium deposits are caused by the consumption of milk and dairy products, in addition, the heart valve problems are mainly caused by gluten-containing cereals, which act like glue.

Symptoms of aortic stenosis

The severity of aortic stenosis varies from mild to severe. The symptoms and signs develop when the narrowing of the valve is severe.
If it is mild to moderate, aortic stenosis is asymptomatic.

It is essential to identify the signs of this disease at the initial stages. Mild calcification can be diagnosed if the following symptoms are observed:

• Heart murmur
• Tightness in the thoracic area
• Angina pectoris
• Palpitations (fast and irregular heartbeat)
• Cough, especially at night
• Swollen ankles and feet
• Fainting or Syncope
• Vertigo
• Dyspnea (shortness of breath) during exertion, which may develop into pulmonary edema

Complications are not always pre-announced by symptoms, so aortic stenosis can lead to sudden death if the person is unaware of this disorder.

The effect of a weakened heart from aortic stenosis can lead to heart failure.
The symptoms and signs of decompensated heart failure include:

• Fatigue
• Shortness of breath
• swelling of the ankles and feet,
• Stomach ache
• abdominal swelling,
• loss of appetite,
• Confusion.

Stenosis manifests itself at a later stage, which is why it is difficult to detect it earlier.
The condition is diagnosed during a routine clinical examination when the doctor hears an abnormal heart tone (heart murmur). This noise can occur much earlier than other signs.
An infant or toddler with aortic stenosis may not have symptoms, but they may tire quickly or have chest pain during intense physical activity.

Complications of aortic stenosis

Severe aortic stenosis can cause heart problems, such as:

• Heart failure
• irregular heart rhythm (arrhythmia),
• dilation of the heart muscle,
• aortic dissection,
• Cardiac arrest and sudden cardiac death.

Diagnosis of aortic valve stenosis

The cardiologist checks the state of health through a physical examination. This includes:

• Listening (auscultation) of the heart (to detect abnormal heart sounds, pulse measurement.

The cardiologist also uses diagnostic imaging to find out what’s going on inside the heart muscle.

The most commonly used diagnostic tests are:

Echocardiogram and Doppler echocardiography: Using an ultrasound probe, images of the heart are displayed.
Doppler echocardiography allows an evaluation of:

• the severity of the flap closure,
• Amount of blood return to the ventricle.

Bidimendional echocardiography provides a detailed picture of the anatomy of the aortic valve, but Doppler sonography is required to quantify the damage.
This is the most important investigation, because it allows the following measurements:

• size of the heart valves,
• movement of the valve sails,
• Presence and extent of limescale deposits.

Fetal echocardiography is used to detect heart malformations in the fetus. Aortic stenosis is only seen from the last trimester of pregnancy.

Cardiac catheterization: A pliable catheter is inserted into a blood vessel that leads to the heart (usually an artery).
It is placed before surgery to exclude occlusion of the coronary vessels.

Table of classification of aortic stenosis according to the pressure gradient

Treatment of aortic stenosis

Medication
medication cannot cure aortic valve stenosis.
The doctor may prescribe some medications that help the heart.

Medical treatment of hypertension (hypertension) is recommended to patients with asymptomatic aortic stenosis.

To reduce the backflow and resistance of blood vessels, the doctor recommends taking the following medications:

• ACE inhibitors (used to reduce blood pressure), initially weak doses, which are then gradually increased to the desired level;
• Calcium antagonists.

To reduce the heart rate, the doctor prescribes digitalis glycosides.

Diet and nutrition for aortic stenosis By lowering blood pressure and cholesterol levels, the development of aortic stenosis
is prevented.

According to the hygienism of Shelton and natural medicine, the cause of calcifications are inorganic salts contained in:

• bottled water,
• vitamin and mineral salt preparations,
• milk and dairy products (mozzarella, yoghurt, cheese, ice cream, etc.),
• cooked food,
• cereals (bread, pasta, rice, etc.),
• transformed food from the supermarket.

Shelton recommends drinking distilled water, i.e. without salts.

In nature, the animals drink water from puddles and rivers, where there are few salts; in addition, they drink little water, since the water contained in the raw foods is practically sufficient.

After the vegan diet / raw food you should limit your diet to the following foods:

• almonds and nuts,
• raw vegetables and fruits,
• Pulses
• Potatoes.

When should surgery be performed for aortic stenosis?

Medication can relieve symptoms, but the only way to eliminate stenosis is surgery to restore or replace the valve.
Surgery is not always urgent. If the examinations show a severity of mild to moderate severity and there are no clinical symptoms, the doctor will schedule a few follow-up appointments to monitor the functioning of the valve.

Statistically, there is a progressive worsening of aortic stenosis and heart valve volume decreases by an average of 0.1 cm each year.².

Surgery becomes an option when the narrowing becomes severe and symptoms develop.

To treat stenosis, the aortic valve can be repaired, but more often it is replaced.

Surgical treatment options to restore or replace an aortic valve:

Balloon valvuloplasty

Balloon valvuloplasty uses a soft and thin tube (catheter) with a balloon at the tip.

• The surgeon guides the catheter through the femoral vein to the heart and into the narrowed aortic valve.
• Positioned there, the balloon expands at the catheter tip.
  The balloon presses against the aortic valve walls and widens the opening, improving blood flow.
• The balloon empties and the catheter is pulled out of the body again.

This surgical procedure improves the signs of aortic stenosis.
However, the procedure brings little success, because the valve narrows again after an initial improvement.
For this reason, doctors rarely recommend balloon valvuloplasty.
Nowadays, this procedure is used for:

• patients in too poor condition for more invasive surgery,
• aortic stenosis of an infant,
• adults or the elderly before performing surgery; in this way, the patient’s state of health improves and the chances of success of the operation increase.

Aortic valve replacement

This is the most widely used method for the treatment of stenosis.
The operation is performed under general anesthesia and with extracorporeal circulation (with heart-lung machine).

There are two ways to gain access to the heart:

• Thoracotomy (surgical opening of the thorax), an incision is made in the 3rd space between ribs.
• Sternotomy (longitudinal transection of the sternum), the surgeon makes a vertical incision in the middle of the bone.

The surgeon:

• severs the pericardium,
• connects the cardiovascular system to a heart-lung machine that replaces these organs during surgery.
• interrupts cardiac activity,
• removes the aortic valve and replaces it with a mechanical or other heart valve made of biological tissue,
• removes limescale deposits during the procedure.

The mechanical valves (metal) are hard and increase the risk of blood clot formation on or near the new implant. If a mechanical valve is implanted, you must take an anticoagulant drug such as warfarin (Coumadin) for life to prevent blood clots. Biological valves (which can come from a pig, cow, or human donor) often need to be replaced after 20-30 years, even if the last generation of valves lasts a lot longer.
A biological prosthesis wears out slightly faster in young people than in older people.

The new prostheses are inserted without seams, they anchor themselves.

Nowadays, the mechanical valves are wider, so a new prosthesis can be inserted later with minimally invasive techniques.
Another type of biological valve replacement is performed from the pulmonary valve (autologous).
The implantation of the aortic valve is carried out via open-heart surgery.

Testimonial of a patient

When I was a child, I was diagnosed with a heart murmur and then aortic and mitral regurgitation was discovered.
Every year I had to go to a cardiologist for check-ups, who did the following examinations:

• echocardiography (cardiac echo) to determine the size of the heart valve,
• Electrocardiogram.

The cardiologist tried to delay the operation as long as possible because heart valves have a limited lifespan and do not last forever.
At that time I received a human heart valve, which is no longer done today.

The procedure is performed:

• under general anesthesia (consequently I saw nothing and felt nothing),
• with heart-lung machine.

A longitudinal transection of the sternum (sternotomy) was performed to gain access to the heart.
The surgery to replace the aortic valve took about 4-5 hours.
I was taken to the operating room at 8 a.m. and woke up around 17 p.m. in the afternoon.
It was very cold in the operating room.
I had eaten for the last time the night before.
When I woke up, I was intubated, which was an unpleasant feeling.
After the procedure, I had a fever every day.
Once I told the nurse that I saw everything blurred with one eye.
I was taken to the ophthalmologist, who saw Candida spores, small embolism formed.

Now a transesophageal echocardiography (swallowing echo) was performed. That hurt because the doctor inserts a device into the throat.
After the first procedure, there was a Candida infection of the heart valve.
I remember being given a medicine into my vein. I felt a burning sensation in the vein, so you had to change the injection site every time.
Because of this complication, the procedure had to be repeated after about 20 days.

Transcatheter Aortic Valve Replacement (TAVI)

This surgical procedure is used for aortic stenosis.
A less invasive procedure (aortic valve replacement via catheter) concerns the replacement of the aortic valve with a valve prosthesis:

• via the femoral artery (transfemoral access),
• from the apex of the heart of the left ventricle (transapical).

When the new flap has reached the correct position, a stent is unfolded that attaches to the old flap.
The old flap remains, but is pressed in by the new one.
As a rule, TAVI is used in patients with an increased risk of surgery.

Criteria to decide whether an intervention is indicated:

• The blood vessels must allow the passage of the catheters, so the state of health must be good.
• The size of the sails must be controlled and occlusion of the coronary arteries excluded.

Complications of this procedure include:

• The release of the heart valve calcification, which enters the bloodstream because the old valve is preserved and the new one is implanted internally. The cardiologist uses a filter to prevent the lime from causing an embolus (and stroke), but the risk remains.
• Cardiac arrest, which is why a pacemaker sometimes needs to be inserted if the structures that control the electrical activity of the heart are damaged during surgery.
• The valve becomes insufficient in about half of the cases.

The procedure takes about 45 minutes, but if the surgeon uses an autoexpansive valve (without a suture), the time is reduced to 30 minutes.

After surgery, the doctor may order treatment with antibiotics before certain medical procedures to prevent the risk of infection of the heart tissue (endocarditis).

• Mitral regurgitation
• Mitral valve prolapse
• Heart murmur