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“If I Have Moderate Aortic Stenosis, Why Should I Wait To Have Valve Replacement Surgery?” Asks Paul

Posted by Adam Pick on January 25th, 2012

I just had a very interesting conversation with Paul about the progression of aortic stenosis and the timing of heart valve replacement surgery.

During our chat, Paul asked, “Adam – I am 71 and have been diagnosed with aortic stenosis for over 10 years now. Recently, the disease progressed from mild to moderate. My cardiologist does not believe surgery is needed yet. I don’t want the stenosis to become ‘severe’ knowing the damage it can cause. Why am I being told to wait for surgery? Thanks, Paul”

Aortic Stenosis Watchful Waiting

Paul asked a great question. That said, I wanted to provide Paul a great answer.

So, I contacted Dr. Ali Khoynezhad, a leading cardiac surgeon at Cedars-Sinai Medical Center in Los Angeles, California. During his career, Dr. Khoynezhad has performed over 1,700 cardiac procedures of which more than 650 involved heart valve surgery.

Dr. Ali Khoynezhad, MD
Dr. Ali Khoynezhad – Cedars-Sinai Medical Center

In his response to Paul’s question, Dr. Khoynezhad first addressed symptoms related to a narrowed, aortic heart valve:

If the patient is asymptomatic and has moderate aortic stenosis, the patient will not require an operation… Because the risk of the operation is greater than ‘watchful waiting’. However, close follow-up with serial echocardiography is warranted — every one to two years.

Dr. Khoynezhad continued to discuss surgical approaches for patients experiencing aortic valve stenosis symptoms:

Onset of symptoms in patients with severe or moderate aortic stenosis is an indication for aortic valve surgery. Outcomes of aortic valve replacement vary significantly at different cardiac centers. Some patients seek their heart surgeon in advance, so they are prepared when they develop symptoms of aortic valve stenosis. Heart valve replacement through a mini-sternotomy is an attractive alternative that cuts down on recovery and hospital stay. This option should be discussed with your heart surgeon. Alternatively, transcatheter valve replacement — without use of heart-lung machine — is also an attractive alternative in high-risk patients with severe aortic stenosis.

Thanks to Paul for his question and a special thanks to Dr. Khoynezhad for sharing his clinical expertise with our community. To learn more about Dr. Khoynezhad, please click here.

Keep on tickin!

Adam Pick
Written by Adam Pick A dad, a husband and a patient, Adam Pick founded this website in 2006 to educate you about heart valve surgery from diagnosis to recovery.
You can get the latest updates about heart valve surgery from Adam at his Facebook, and Twitter pages. Click here to email him.


Dave Harris says on January 25th, 2012 at 2:30 pm

Patients with aortic stenosis can be observed for many years, and the situation usually remains stable. Once symptoms ensue, ie shortness of breath, dizziness or fainting spells, or chest pain, the risk of sudden death rises exponentially, so valve replacement should then be done soon.
Sometimes severe stenosis may be misdiagnosed as moderate if it is longstanding and the heart function has deteriorated. Then the gradient over the valve is lower than expected, and it can be assumed moderate. The poorly contracting heart now cannot generate the same gradient anymore. Also if there is coronary disease the function is less, so the gradient less. Sometimes there can be sudden increase in the stenosis and there can be rapid deterioration…so beware.
Coronary disease should also be looked for so CT angiogram of the coronaries is useful. If you have associated coronary disease such as a mainstem or proximal LAD lesion, you would then need valve replacement together with coronary bypass. The coronary disease would be the primary reason for the operation, but if there is moderate stenosis present AVR should be done at the same time.
In asymptomatic aortic stenosis an exercise EKG will be positive if the stenosis is more severe than initially diagnosed.
Dave Harris, Cardiac surgeon


Gene Parrish says on January 25th, 2012 at 2:57 pm

I have moderate aortic regurgitation and I am asymptomatic – valve is bicuspid. Do the same guidelines apply to my situation? I am a 61 year old male, and had open chest surgery three years ago to repair an ascending aortic aneurysm. The valve was not regurgitant at the time of my operation, so the surgeon decided that I would be better off to keep my native valve for as long as it would last.


Dave Harris says on January 25th, 2012 at 3:14 pm

As soon as you mentioned bicuspid valve, I immediately started wondering about your ascending aorta. Bicuspid valves are associated with aneurysms of the ascending aorta. If the valve primarily needs replacement, the ascending aorta should be replaced too if it measures 4.0cm. Normally an ascending aorta should be replaced if it measures over 5.0cm.
Regurgitation is a different problem, and patients are asymptomatic until the heart is too dilated and the function too far depressed to survive surgery. Patients with stenosis are `protected` by development of symptoms.
You are better off with your own valve tissue, even if it does not function perfectly. But you will need 6 monthly check with echo or chest x ray. It is possible the situation will remain stable, however as soon as there is an increase in size in the left ventricle (which occurs long before symptoms occur)the valve should be replaced. Once the ventricle starts to stretch then the process starts to continue at an ever rapid pace (over month to years, but this can be unpredictable).
Dave Harris, Cardiac surgeon


Kerrigan says on January 25th, 2012 at 5:37 pm

At 65 the watchful waiting of the asymptomatic bad valve turned into “you’ll probably have a severe symptom, like a heart attack, within 2-4 months.” Thinking it was better to operate on a “healthy heart” instead of waiting for it to be damaged, I opted for the surgery with a pig tissue valve.
No life-time blood thinners are required and the valve has an estimated 10-15 year trouble-free life.
For myself and my family, it was the right decision.
Recovery was successful and not too difficult because the heart had not been damaged.


Audrey Schmida says on January 25th, 2012 at 8:31 pm

It doesn`t matter what anyone tells you; knowing that inevitably you have to have heart surgery makes it harder to accept that you are being diagnosed with a “waiting period”, in which any kind of heart damage can occur. I have the same diagnosis…..I am too healthy fo open heart valve repair.


Tawnya Crawford says on January 26th, 2012 at 1:23 pm

I have a similar question for a pediatric patient.

here’s our background:
my daughter is 5. small, 1-5th percentile weight, 7th% height, with suspected, yet unidentified connective tissue disorder with cardiac involvement. all heart valves affected, mitral most seriously. she also has supravalvular aortic stenosis. she is currently on enalapril 1.5 ml/twice daily. blood pressures typically 90/50. highlights of latest echo: abnormal, prolasping mitral and tricuspid vavles, upper moderate mitral regurg, dilated left ventrical, mild dilated left atrium, normal left ventricular systolic function, shortening fraction 31%, ejection fraction 59%, mild flow acceleration in the ascending aorta, (her aortic root diameter is at the minumum for her size)
we have noticed a signifigant decline in her activity tolerance in the last couple months. she is always pale and gray around her mouth, hands and feet. she often ‘grunts’ when breathing. her heart rate is irregular most of the time (normal sinus arrhythmia). she is now complaining of her “head hurting” often and feeling “shaky”.

finally, my question….from what i understand, the mitral valve will have to be replaced. although her overall function is still acceptable (according to her cardiologist), we feel we are walking a fine line before heart failure begins. what would you advise, generally, for timing of this surgery? what are the most concerning risk/benefits? in a nutshell, should we wait for verifiable heart failure criteria before risking surgery, or would that be too late? can valves be replaced on a heart with muscle damage?
thanks for the opinion,
tawnya crawford


Audrey Schmida says on January 26th, 2012 at 8:32 pm

Has her doctor scheduled her for any additional tests?


Tawnya Crawford says on January 26th, 2012 at 11:43 pm

Audrey…and others,

i am to take her to the ER during her next ‘headache’ episode for another echo. i have had her blood pressure taken during these episodes and her diastolic pressure was raised to 78-88, which is significantly higher than her ‘normal’ in the 50s. dr doesn’t believe this is possible. ???
additionally, the dr is considering and consulting with the cath team about a rt heart cath to verify her echo numbers. it is my understanding that her echo report shows just shy of heart failure numbers, but with her symptoms, i am very concerned.
i have no experience with heart disease and i am confused about how her ‘symptoms’ come and go. one day she can run around and play and the next she can’t.


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