ImportanceCalcific aortic stenosis (AS) restricts the aortic valve opening during systole due to calcification and fibrosis of either a congenital bicuspid or a normal trileaflet aortic valve. In the US, AS affects 1% to 2% of adults older than 65 years and approximately 12% of adults older than 75 years. Worldwide, AS leads to more than 100 000 deaths annually.ObservationsCalcific AS is characterized by aortic valve leaflet lipid infiltration and inflammation with subsequent fibrosis and calcification. Symptoms due to severe AS, such as exercise intolerance, exertional dyspnea, and syncope, are associated with a 1-year mortality rate of up to 50% without aortic valve replacement. Echocardiography can detect AS and measure the severity of aortic valve dysfunction. Although progression rates vary, once aortic velocity is higher than 2 m/s, progression to severe AS occurs typically within 10 years. Severe AS is defined by an aortic velocity 4 m/s or higher, a mean gradient 40 mm Hg or higher, or a valve area less than or equal to 1.0 cm2. Management of mild to moderate AS and asymptomatic severe AS consists of patient education about the typical progression of disease; clinical and echocardiographic surveillance at intervals of 3 to 5 years for mild AS, 1 to 2 years for moderate AS, and 6 to 12 months for severe AS; and treatment of hypertension, hyperlipidemia, and cigarette smoking as indicated. When a patient with severe AS develops symptoms, surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) is recommended, which restores an average life expectancy; in patients aged older than 70 years with a low surgical risk, 10-year all-cause mortality was 62.7% with TAVI and 64.0% with SAVR. TAVI is associated with decreased length of hospitalization, more rapid return to normal activities, and less pain compared with SAVR. However, evidence supporting TAVI for patients aged younger than 65 years and long-term outcomes of TAVI are less well defined than for SAVR. For patients with symptomatic severe AS, the 2020 American College of Cardiology/American Heart Association guideline recommends SAVR for individuals aged 65 years and younger, SAVR or TAVI for those aged 66 to 79 years, and TAVI for individuals aged 80 years and older or those with an estimated surgical mortality of 8% or higher.ConclusionsCalcific AS is a common chronic progressive condition among older adults and is diagnosed via echocardiography. Symptomatic patients with severe AS have a mortality rate of up to 50% after 1 year, but treatment with SAVR or TAVI reduces mortality to that of age-matched control patients. The type and timing of valve replacement should be built on evidence-based guidelines, shared decision-making, and involvement of a multidisciplinary heart valve team.

中文翻译：

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 钙化性主动脉瓣狭窄


重要性钙化性主动脉瓣狭窄 （AS） 由于先天性二叶式或正常三叶主动脉瓣的钙化和纤维化，限制了收缩期主动脉瓣的打开。在美国，AS 影响 1% 至 2% 的 65 岁以上成年人和约 12% 的 75 岁以上成年人。在全球范围内，AS 每年导致超过 100 000 人死亡。观察钙化性 AS 的特征是主动脉瓣叶脂质浸润和炎症，随后纤维化和钙化。重度 AS 引起的症状，例如运动不耐受、劳力性呼吸困难和晕厥，与不进行主动脉瓣置换术的 1 年死亡率高达 50% 相关。超声心动图可以检测 AS 并测量主动脉瓣功能障碍的严重程度。尽管进展速度各不相同，但一旦主动脉速度高于 2 m/s，通常会在 10 年内进展为重度 AS。严重 AS 定义为主动脉速度 4 m/s 或更高，平均梯度 40 mm Hg 或更高，或瓣膜面积小于或等于 1.0 cm2。轻至中度 AS 和无症状重度 AS 的管理包括：对患者进行有关疾病典型进展的教育;轻度 AS 每隔 3 至 5 年进行一次临床和超声心动图监测，中度 AS 每隔 1 至 2 年一次，重度 AS 每隔 6 至 12 个月进行一次;以及治疗高血压、高脂血症和吸烟（如有指征）。当重度 AS 患者出现症状时，建议进行外科主动脉瓣置换术 （SAVR） 或经导管主动脉瓣植入术 （TAVI），以恢复平均预期寿命;在 70 岁以上且手术风险低的患者中，TAVI 的 10 年全因死亡率为 62.7%，SAVR 为 64.0%。 与 SAVR 相比，TAVI 与住院时间缩短、恢复正常活动更快和疼痛减轻有关。然而，支持 65 岁以下患者使用 TAVI 的证据以及 TAVI 的长期结局不如 SAVR 明确。对于有症状的重度 AS 患者，2020 年美国心脏病学会/美国心脏协会指南建议对 65 岁及以下的个体进行 SAVR，对 66-79 岁的个体进行 SAVR 或 TAVI，对 80 岁及以上或估计手术死亡率为 8% 或更高的个体进行 TAVI。结论钙化性 AS 是老年人中常见的慢性进行性疾病，通过超声心动图诊断。有症状的重度 AS 患者 1 年后死亡率高达 50%，但 SAVR 或 TAVI 治疗可将死亡率降低至年龄匹配的对照患者。瓣膜置换术的类型和时间应建立在循证指南、共同决策和多学科心脏瓣膜团队的参与基础上。