Aortic valve stenosisAortic valve regurge

Aortic valve disease

By Prof. Hatem Abdel Rahman

MD cardiology Dr. Mohamd Ashraf Ahmad

MD cardiology

Aortic Stenosis

Definition Aortic stenosis

refers to obstruction of flow from the LV to aorta.

Anatomically, It may be:1-Valvular:2- Subvalvular:3-Supravalvular :

Aortic valve Stenosis

Etiologies

Congenital 0-30 yrsBicuspid 30-50 yrsRheumatic 30-60 yrsDegenerative >60 yrs

Aortic valve Stenosis

Pathophysiology

Valvular aortic stenosis results in chronic left ventricular pressure overloading.

Compensatory concentric LVH allows the ventricle to maintain stroke volume with increases in diastolic pressure, and patients remain asymptomatic for many years.

Later on, LVH causes either Diastolic dysfunction with the onset of

congestive symptomsMyocardial oxygen needs in excess of

supply with the onset of angina. Some patients might also experience

exertional syncope, probably reflecting the inability to increase cardiac output and maintain blood pressure in response to vasodilation.

Clinical presentation- Asymptomatic - The classic symptoms of severe AS:

1- Angina. 2- Syncope. 3- Congestive heart failure. 4-Sudden cardiac death.

Aortic Stenosis

Natural history of aortic stenosis. At the onset of symptoms (arrow), there is a rapid progression and survival is severely limited

On examination:

 Delayed slow-rising carotid upstroke (pulsus parvus et tardus).

Sustained left ventricular apical impulse. Fourth heart sound. Harsh systolic murmur of aortic stenosis,

loudest at the base of the heart and radiating to the carotids, is often but not always prominent. Low output states, obesity, or chronic lung disease may mask the findings.

Other hallmarks of significant aortic valve stenosis include a single (pulmonic) component of the second heart sound.

InvestigationsECG often shows changes of left ventricular

hypertrophy. The chest X ray occasionally shows heavy

calcification of the valve or ascending aortic dilation.

Echocardiography: Test of choice in the evaluation of patients with suspected valvular disease. It allows assessment of the valve anatomy as well as of chamber size and ventricular function. Doppler studies permit estimation of pressure gradients and estimations of aortic valve area .

Stress ECG:Cardiac catheterization: It is generally performed as preoperative

coronary angiography in men older than 35 years, women older than 45 years to exclude coronary artery disease.

TreatmentMedical:

To date, no medical therapy exists for the treatment of calcific aortic stenosis.

Prophylaxis against recurrent rheumatic fever in rheumatic patients.

Antibiotic prophylaxis against infective endocarditis in conditions associated with bacteraemia.

Surgical:Aortic valve replacementPercutaneous:

TAVR

Indications for surgery 1- Symptomatic patients (i.e., those

with angina, syncope, or dyspnea) with severe aortic stenosis should undergo valve replacement.

2- Patients with severe AS undergoing coronary artery bypass grafting

3- Patients with severe AS undergoing

surgery on the aorta or other heart valves .

3- Asymptomatic Patients with severe AS and left ventricular ejection fractions less than 0.50.

4- Patients with moderate aortic stenosis undergoing coronary artery bypass grafting or surgery on the aorta or other heart valves (Class IIa indication).

5- Aymptomatic patients with severe AS who exhibit an abnormal response to exercise (hypotension).

Questions???

Aortic Regurgitation

Aortic RegurgitationEtiologyPhysical ExaminationAssessing SeverityNatural History PrognosisTiming of Surgery

Etiology of AR

CongenitalBicuspid valve

AcquiredRheumatic heart

diseaseDilated aorta (e.g.

hypertension..)DegenerativeConnective tissue

disorders E.g. ankylosing

spondylitis, rheumatoid arthritis, Reiter’s syndrome, Giant-cell arteritis )

AortopathyCystic medial

necrosisCollagen disorders

(e.g. Marfan’s)Ehler-DanlosOsteogenesis

imperfecta.

Acute AI: aortic dissection, infective endocarditis, trauma

:Pathophysiology of ARAcute or subacute significant AR

causes the abrupt introduction of a large volume of blood into a noncompliant LV, thus increasing LV end-diastolic and pulmonary venous pressures and leading to acute dyspnea or pulmonary edema.

In chronic AR, compensatory LV changes occur over time. The excess volume load causes stretching and elongation of myocardial fibers, which in turn increase wall stress.

When the ventricle can not dilate further, diastolic pressure increases and results in dyspnea, another sign of decompensation.

Symptoms of ARDyspnea, orthopnea, PNDPalpitations.Chest pain.

Nocturnal angina >> exertional angina ( diastolic aortic pressure and increased

LVEDP thus coronary artery diastolic flow).

With extreme reductions in diastolic pressures (e.g. < 40 mmHg) may see angina

Peripheral Signs of Severe ARQuincke’s sign:

capillary pulsationCorrigan’s sign:

water hammer pulse

De Musset’s sign: systolic head bobbing

Mueller’s sign: systolic pulsation of uvula

Durosier’s sign: femoral retrograde bruits

Traube’s sign: pistol shot femorals

Hill’s sign: BP Lower extremity >BP Upper extremity by > 20 mm Hg - mild AR> 40 mm Hg – mod AR> 60 mm Hg – severe

AR

Cardiac Signs of Severe AR

Apex:DisplacedHyper-dynamicPalpable S3 Austin-Flint

murmur

Murmur of aortic regurge:High pitched,

blowing, decrescendo diastolic murmur at LSB best heard at end-expiration & leaning forward

length correlates with severity (chronic AR)

in acute AR murmur shortens as Aortic DP=LVEDP

Assessing Severity of AR Assess severity by impact on peripheral

signs and LV peripheral signs = severityDilated LV = severityS3Austin –FlintRadiological cardiomegaly

Investigations ECGChest X rayEchocardiographyStress ECGCoronary angiography (preop.)

Echo Indications for Valve Replacement in Asymptomatic AR & MR

Type of Regurgitatio

n

LVESD mm

EF %

FS

Aortic >55 < 55 < 0.27

Mitral >45 < 60 <0.32

Indication for Valve Replacement in severe AR :

ACC/AHA Class ISymptomatic patients with preserved LVF

(LVEF >50%)Asymptomatic

Patients with mild to moderate LV dysfunction (EF 25-49%)

Patients undergoing CABG, aortic or other valvular surgery

ACC/AHA Class II aAsymptomatic patients with preserved

LVEF but severe LV dilatation (EDD>75 mm or ESD > 55mm)

Questions????