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1 Other rare causes are familial hypercholesterolaemia, hyperuricaemia, hyperparathyroidism, Paget disease, ochronosis, Fabry disease, lupus erythematosus, and drug-induced diseases. The ‘degenerative’ aetiology accounts for 80% of cases in Western countries followed by rheumatic disease, which is characterized by commissural fusion and fibrosis, with retraction and stiffening of the cusps.
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Calcification begins at the base of the cusps and progresses towards the edges, while the commissures remain open (Figure 35.3.1). The frequency of AS observed on bicuspid valves is higher in patients aged less than 60, and then the trend is inverted afterwards. 5 However, it has to be emphasized that this distribution is highly dependent on the age of the study population. In surgical series, bicuspid valves account for approximately 50%, tricuspid valves 30–40%, and rare unicuspid valves less than 10%. IntroductionĪS is most often due to calcification of a normal tricuspid valve or a congenitally bicuspid valve (see Chapter 46.19). Although current data favour TAVI in elderly patients who are at increased risk for surgery, particularly when a transfemoral access is possible, the decision between TAVI and SAVR should be made by the Heart Team after careful, comprehensive evaluation of the patient, weighing individually risk and benefit. The presence of predictors of rapid symptom development can justify early surgery in asymptomatic patients, particularly when surgical risk is low. The strongest indication for intervention remain symptoms of aortic stenosis (spontaneous or on exercise testing). The assessment of the severity of aortic stenosis in patients with low gradient and preserved ejection fraction remains particularly challenging.
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The diagnosis of severe aortic stenosis requires consideration of AVA together with flow rate, pressure gradients (the most robust measurement), ventricular function, size and wall thickness, degree of valve calcification and blood pressure, as well as functional status.
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