eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology

Aortic Stenosis, Valvar: Follow-up

Author: Howard S Weber, MD, FAAP, FACC, FSCAI, Professor, Assistant Chief, Section of Pediatric Cardiology, Penn State University School of Medicine; Director, Pediatric Catheterization Laboratory, Milton S Hershey Medical Center
Coauthor(s): Paul M Seib, MD, Associate Professor of Pediatrics, University of Arkansas for Medical Sciences; Medical Director, Cardiac Catheterization Laboratory, Co-Medical Director, Cardiovascular Intensive Care Unit, Arkansas Children's Hospital
Contributor Information and Disclosures

Updated: Sep 29, 2009

Follow-up

Further Inpatient Care

  • Manage congestive heart failure in patients with aortic valve stenosis.
  • Monitor for arrhythmias and initiate antiarrhythmic therapy as needed.
  • Monitor postprocedural or postsurgical recovery.
  • Provide patient education.

Further Outpatient Care

  • Manage congestive heart failure.
  • Provide physical rehabilitation.
  • Perform exercise stress testing to determine response to therapy or activity restrictions.
  • Provide patient education.

Inpatient & Outpatient Medications

  • Use subacute bacterial endocarditis (SBE) prophylaxis for indicated procedures.
  • Prescribe other medicines as indicated for treatment of specific conditions such as congestive heart failure and arrhythmias.

Transfer

  • Transfer to a center capable of providing specialized care for infants and children with aortic stenosis.
  • In those cases of aortic stenosis diagnosed prenatally, the mother should be referred for delivery at a center capable of providing specialized care for newborns with severe aortic stenosis, which includes the immediate initiation of intravenous prostaglandin E1.

Deterrence/Prevention

  • Fetal echocardiography is indicated for all subsequent pregnancies following the birth of a child with congenital aortic valve stenosis. When critical aortic stenosis is identified prenatally, delivery should take place in a tertiary center prepared to care for a neonate with severe aortic stenosis. Identified genetic abnormalities (eg, Turner syndrome or monosomy X) indicate the need for screening of parents to look for evidence of translocation.

Complications

  • Congestive heart failure
  • Myocardial injury and fibrosis
  • Syncope
  • Endocarditis
  • Calcific aortic stenosis
  • Progressive aortic insufficiency
  • Systemic embolization
  • Arrhythmias
  • Sudden death

Prognosis

  • The prognosis for patients with congenital aortic valve stenosis depends on the valve anatomy and its response to intervention. The severity of the disorder is widely varies, ranging from no symptoms in children with only a bicuspid aortic valve and minimal stenosis to critical illness in neonates who face the prospect of serial interventions. The main goal is to preserve the native aortic valve and ventricular function for as long as possible until aortic valve replacement is necessary.

Patient Education

  • Education is indicated for affected families regarding signs of progressive aortic stenosis, congestive heart failure, and low cardiac output. Education regarding good dental care and avoidance of risk factors for endocarditis is imperative. Other goals of parent education include setting reasonable goals for exercise participation that allow for a healthy lifestyle but downplaying long-term goals for competitive athletics at a high level until complete relief of aortic valve disease is accomplished by aortic valve repair or replacement.
  • Similarly, emphasize that treatment of aortic valve disease is a lifelong process and is best introduced early and reinforced often to ensure that patients with aortic valve stenosis continue to receive ongoing follow-up care as they make the transition from an adolescent lifestyle at home to the independent lifestyle of young adulthood.

Miscellaneous

Medicolegal Pitfalls

  • Failure to provide good patient education to help parents of children with aortic valve stenosis understand the severity and long-term nature of aortic valve disease and the long-term commitment to surveillance and appropriate intervention
  • Failure to explain potential risks of interventions, in particular, potential complications of surgical or balloon valvotomy
  • Failure to emphasize risks of anesthesia and bypass for surgical valvotomy or for balloon valvotomy, cardiac perforation, acute low cardiac output from aortic insufficiency, and acute myocardial dysfunction

Special Concerns

  • The choice of an aortic valve for aortic valve replacement may be more complicated in female patients contemplating pregnancy.
  • The choice of a mechanical valve, a bioprosthetic valve, or a Ross procedure should be reviewed at length for all patients, particularly those contemplating valve replacement.
  • Teratogenic effects of warfarin, management issues of anticoagulation during pregnancy, and need for reoperation, as well as durability of various valve options, should be reviewed at length.
 


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References
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Further Reading

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Keywords

valvar aortic stenosis, left ventricular outflow tract obstruction, aortic valve stenosis, supravalvar aortic stenosis, subvalvular aortic stenosis, valvular aortic stenosis, exercise-induced syncope, myocardial ischemia, congestive heart failure, bicuspid aortic valve, patent ductus arteriosus, coarctation of aorta, ventricular septal defect, mitral valve abnormalities, left ventricular hypoplasia, cardiac murmur, chest pain, hypoplastic left heart syndrome, Turner syndrome

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Contributor Information and Disclosures

Author

Howard S Weber, MD, FAAP, FACC, FSCAI, Professor, Assistant Chief, Section of Pediatric Cardiology, Penn State University School of Medicine; Director, Pediatric Catheterization Laboratory, Milton S Hershey Medical Center
Howard S Weber, MD, FAAP, FACC, FSCAI is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Coauthor(s)

Paul M Seib, MD, Associate Professor of Pediatrics, University of Arkansas for Medical Sciences; Medical Director, Cardiac Catheterization Laboratory, Co-Medical Director, Cardiovascular Intensive Care Unit, Arkansas Children's Hospital
Paul M Seib, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, Arkansas Medical Society, International Society for Heart and Lung Transplantation, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Medical Editor

Juan Carlos Alejos, MD, Clinical Professor, Department of Pediatrics, Division of Cardiology, University of California at Los Angeles
Juan Carlos Alejos, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, American Medical Association, and International Society for Heart and Lung Transplantation
Disclosure: Actelion Honoraria Speaking and teaching

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

John W Moore, MD, MPH, Professor of Clinical Pediatrics, Section of Pediatric Cardiology, Department of Pediatrics, University of California San Diego School of Medicine; Director of Cardiology, Rady Children's Hospital
John W Moore, MD, MPH is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

CME Editor

Gilbert Z Herzberg, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College; Consulting Staff, Department of Pediatrics, Sound Shore Medical Center
Gilbert Z Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Chief Editor

Steven R Neish, MD, SM, Director of Pediatric Cardiology Fellowship Program, Associate Professor, Department of Pediatrics, Baylor College of Medicine
Steven R Neish, MD, SM is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, and American Heart Association
Disclosure: Nothing to disclose.

 
 
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