By Ryan DuBosar
The aorta isn't “just kind of a lump of fibrous tissues,” said Kelley R. Branch, MD, MSc, ACP Member. Instead, he asked attendees to think about the valve's impressively complex structure.
The aorta has endothelial cells, collagen, interstitial cells, and elastin comprising three layers, the fibrosa, spongiosa, and ventricularis. The interplay between collagen and elastin allow it to open, but not too far, and close, but not too tight, Dr. Branch said.
“It's durable," he said, “And if you think about what this poor thing has to do; this has to open and close 2.5 to 3 billion cycles over its lifetime.”
When he examines a patient for aortic valve stenosis, he follows a few mantras to guide him, he told attendees Thursday at Internal Medicine Meeting 2026.
The most important tool in that exam is not the stethoscopes, he said. “It's our ability to talk with our patients.”
Dr. Branch's first mantra for a patient with valvular disease starts with taking a history, specifically looking at functional status: exercise capacity, mobility on flat surfaces and inclines, and exercise tolerance. For that last point, he clarifies that the question is what the patient can currently do, rather than what they were capable of in the past.
His next mantra assesses symptoms such as chest pain and dyspnea, and then, “A physical examination can be very helpful.” This includes blood pressure, heart rate, and signs that would guide a diagnosis, such as a diastolic or systolic murmur, apical displacement, right ventricular heave, and any manifestations such as jugular venous pressure.
These findings are useful but are not the final determinants of treatment, he noted. “When are we supposed to do something? And what it comes down to, again and again, is symptoms," Dr. Branch said. “So if they have symptoms, then we really want to know.”
If a patient has a stenotic valve, hypertrophy will manifest like a bicep after a workout: It looks bigger. For the aorta, pressure overload results in later dilation. The signs and symptoms of this pressure overload phenomenon are going to be dyspnea and exercise intolerance.
For the regurgitant valve, the volume overload causes dilation rather than hypertrophy, “and so valve tissue ends up getting really, really stringy and stretchy as it's going back and forth,” he said. This also manifests as dyspnea and exercise intolerance, but there may or may not be chest pain, as with a stenotic valve. “You're looking more for dilation rather than hypertrophy, and the onset can be rather insidious,” said Dr. Branch.
Dr. Branch left the audience with a final mantra, a mnemonic to remember the classes of disease set out in the American College of Cardiology and American Heart Association's 2020 guideline for the management of patients with valvular heart disease.
The lead author of that report, Catherine M. Otto, MD, at the University of Washington (who is Dr. Branch's former program director), created a way to translate the criteria from the guideline into practice, what Dr. Branch called “a way of trying to remember what these things are” when talking to patients.
For patients with risk factors for development of valvular heart disease (VHD), Class A means Aware. “So if you're stage A, that means you're at risk,” Dr. Branch said. For patients with manifestations of progressive VHD (mild-to-moderate severity and asymptomatic), Class B means Be vigilant.
“That means we need to have some kind of follow-up over time, and we're going to see what those are over time,” he said. Asymptomatic patients who meet criteria for severe VHD and whose left or right ventricle remains compensated fall into Class C1, which can be described by the advice to Chill.
“Whether or not they're symptomatic or asymptomatic makes a big deal. If they're asymptomatic and severe, [but] they remain compensated, then we could chill out. We don't need to be doing anything right then,” said Dr. Branch.
Asymptomatic patients with severe VHD with decompensation of the left or right ventricle fall into Class C2, Could Consider surgery. “That's when you could consider doing some kind of intervention at that point, right? Because the horse is starting to leave the barn,” he said.
Patients who have developed symptoms from VHD fall into Class D, just Do it. “That means the patient needs intervention because they're going to further decompensate,” Dr. Branch said. “That's what we don't want to have." ■