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Aortic diseases
- 2. VALVE VESSEL Stenosis Dissection (AS) Regurgitation (AR) Mixed(AS+AR) Anuerysm
- 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. 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. Severe AS Late peaking murmer Fourth heart sound Thrill Reverse split
- 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. Causes Bicuspid aortic valve(young) Degenerative(elderly) Rhuematic SLE,hyperlidaemia,oochronosis(rare)
- 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. Aortic Stenosis: Physical Findings S1 S2 S1 S2
- 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. 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
- 13. Medical management Antibiotic prophylaxis for endocarditis Treat AF vigorously-amiodarone Avoid; CCB ACEI/ARB‟S Digoxin Nitrates Betablockers cautiously.
- 14. Surgical Aortic balloon valvuloplasty Congenital AS Palliation in elderly Bridge to AVR in critically ill 50% restenosis in six months
- 15. Rule of „Five‟ LVEDD>55mm EF<55% Gradient>50mm Hg
- 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. 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. Valve replacement Mechanical(Bileaflet valves) Tissue Ross manouver. AV debridement.No appreciable benefit.Restenosis almost invariable.
- 20. 1. 2. 3. 4. Usually aymptomatic until middle age Left sided failure or chest pain. Long list of causes Charecteristic physical signs
- 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. 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. Symptoms Palpitations Symptoms of heart failure(Fatigue,weakness) Exertional dysponea,orthopnea,PND
- 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. Management Acute AR-VD,inotropes,surgery chronicAR control HTN antiarryhmics diuretics ACEI/ARB‟s nitrates low dose beta blockers inotropes,digoxin SBE prophlaxis
- 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. 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. THANK YOU “for patient listening”