Aortic diseases

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Aortic diseases

  1. 1. AORTIC DISEASES Dr Mohammad Ali Khalid
  2. 2.  VALVE  VESSEL  Stenosis  Dissection (AS)  Regurgitation (AR)  Mixed(AS+AR)  Anuerysm
  3. 3. Aortic stenosis  Normal valve area 2.4-5.5cm2  Normal pressure gradient across valve upto 11 mm hg  Normal cusp seperation 15-25mm
  4. 4. Essentials of diagnosis         Chest pain Dysponea Effort syncope Arrythmias(tachycardias,VPC‟s,VT,AF) Pulse parvus et tardus Heaving apex beat Ejection systolic murmer left upper sternal edge radiating to carotids Thrill?
  5. 5. Severe AS  Late peaking murmer  Fourth heart sound  Thrill  Reverse split
  6. 6. General considerations  Narrowing of aortic valve leaflets  Calcification  Impedence to blood flow  Increased LV workload  Relative blood supply insufficiency-Angina  Finally LVF  Exertional syncope  Sudden death
  7. 7. Causes  Bicuspid aortic valve(young)  Degenerative(elderly)  Rhuematic  SLE,hyperlidaemia,oochronosis(rare)
  8. 8. SYMPTOMS &SIGNS  Palpitations especially on effort  Angina  Syncopal attacks  Breathlessness  Frank CCF  charecteristic  Heaving pulse apex  Murmer  Fourth heart sound  Thrill  Reverse split
  9. 9. Aortic Stenosis: Physical Findings S1 S2 S1 S2
  10. 10. Investigations  ECG-LVH,Ischaemia,AF,other  CXR-increased changes CTR,CCF  Echo-valve area,flow rate,cusp seperation,gradient,LV dimensions  Cardiac catheterization
  11. 11. Cath studies  SEVERITY GRADIENT  Mild <25  Moderate 26-50  Severe >50  Critical >80 AVA(cm2) >1.5 1.0-1.5 <1.0 <0.7
  12. 12. Treatment  Pharmacological(symptomatic/palliative)  Surgical(definitive)
  13. 13. Medical management     Antibiotic prophylaxis for endocarditis Treat AF vigorously-amiodarone Avoid; CCB ACEI/ARB‟S Digoxin Nitrates Betablockers cautiously.
  14. 14. Surgical  Aortic     balloon valvuloplasty Congenital AS Palliation in elderly Bridge to AVR in critically ill 50% restenosis in six months
  15. 15. Rule of „Five‟  LVEDD>55mm  EF<55%  Gradient>50mm Hg
  16. 16. Surgery  Heart failure  Syncope  Angina  Survival drops sharply once these features develop.75% of patients dead within three years if surgery refused or could not be carried out.  AS +CAD has worse prognosis.
  17. 17. AHA/ACC guidelines Class I  Symptomatic severe AS  Asymptomatic severe AS but undergoing other cardiac surgery Class II    Asymptomatic moderate AS undergoing other cardiac surgery Asymptomatic severe AS+LVF Abnormal exercise response
  18. 18. Valve replacement  Mechanical(Bileaflet valves)  Tissue  Ross manouver.  AV debridement.No appreciable benefit.Restenosis almost invariable.
  19. 19. AORTIC REGURGITATION
  20. 20. 1. 2. 3. 4. Usually aymptomatic until middle age Left sided failure or chest pain. Long list of causes Charecteristic physical signs
  21. 21. Causes         Rhuematic fever Infective endocarditis Degerative Calcific(usually with AS) Acute MI Trauma Aortic root diseae Aortic dissection        Hypertension Dilated cardiomyopathy Syphilis Marfans syndrome Osteogenesis imperfecta Other collagen diorders Spondyloarhropathy
  22. 22. Physical signs         Pulse(water hammer) Quinke‟s sign Lighthouse sign Corrigan‟s pulse Demusset‟s sign Pistol shots over femoral pulse(traube‟s sign) Drouziez murmer Hill sign       Heaving apex Early diastolic murmer at LUSE Other signs of LV dysfunction/CCF S4,S3 Austin flint murmer Signs related to any other underlying cause
  23. 23. Symptoms  Palpitations  Symptoms of heart failure(Fatigue,weakness)  Exertional dysponea,orthopnea,PND
  24. 24. Investigations  CXR-increased CTR,pulmonary congestion  ECG-LVH with strain,ischaemia,arrythmias  Echo-diagnostic LV dimensions degree of regurgitation ejection fraction  Cath studies,CT,MRI
  25. 25. Management           Acute AR-VD,inotropes,surgery chronicAR control HTN antiarryhmics diuretics ACEI/ARB‟s nitrates low dose beta blockers inotropes,digoxin SBE prophlaxis
  26. 26. Surgery in AR  Acute AR  ChronicAR-NYHA 3-4  EF>55 but<35  LVED>55  Valve replacement only  Reconstructive surgery not an option
  27. 27. Prognosis  Asymptomatic with normalLV function     Asymptomatic patients with LV dysfunction   progression to ccf <6%/year Progression to asymptomatic LV dysfunction <3.5%/year Sudden death 0.2%/year Progression to cardiac symptoms>25%/year Symptomatic patients  Mortality rate >10%/year
  28. 28. THANK YOU “for patient listening”
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