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1. AORTIC STENOSIS
GURJEET SINGH
VIII TERM

2. WHAT IS AORTIC STENOSIS
 Aortic stenosis (AS) is narrowing of the aortic
valve resulting in obstruction of blood flow from
the left ventricle to the ascending aorta during
systole

3. Normal aortic valve
surface area is 03 – 04 cm2
Narrowing of aortic orifice is
called aortic stenosis

4. ANATOMY
 Semi lunar shaped
 Three cups
 Large lumen=low resistance
 Elastic a flexible
 Pressure reservoir

5. ETIOLOGY

7. Rheumatic Heart Disease
Aortic stenosis is accompanied by Aortic insufficiency and/or
mitral valve disease

8. Aortic Stenosis Mimickers
• Subvalvular Stenosis
+ Hypertrophic Cardiomyopathy
+ Subvalvular Membrane
• Supravalvular Stenosis
+ William Syndrome (hypercalcemia, growth failure and
mental retardation)

9. PATHOPHYSIOLOGY
 AORTIC STENOSIS

 INCREASED OUTFLOW OBSTRUCTION
 INCREASE LV PRESSURE
 COMPENSATORY LEFT VENTRICULAR HYPERTROPHY
 INCREASED LVEDV

10. CONT.
 Subendocardial ischaemia ( myocardial perfusion pressure)
progressive valvular obstruction and wall stress
filling pressure,ventricular dilation , contractile dysfunction
ischaemia, arrythmia
 ANGINA,SYNCOPE, DYSPNEOA

11. SYMPTOMS
 Congenital AS is usually asymptomatic until age 10 or 20 yr, when symptoms develop insidiously. In all
forms, progressive untreated AS ultimately results in exertional syncope, angina, and dyspnea (SAD
triad). Other symptoms and signs may include those of heart failure and arrhythmias, including
ventricular fibrillation leading to sudden death.
 The classic symptoms due to AS are heart failure (HF), syncope, and angina. However, these “classic”
symptoms reflect end-stage disease. Now, with earlier diagnosis by echocardiography and prospective
followup of patients, the most common presenting symptoms are:
• Dyspnea on exertion or decreased exercise tolerance
• Exertional dizziness
• Exertional angina
 Heyde's syndrome is a syndrome of aortic valve stenosis associated with gastrointestinal bleeding
from colonic angiodysplasia.

12. PHYSICAL SIGNS
 The quality of the arterial pulse reflects the obstruction to blood flow into the peripheral arterial
circulation.
 The arterial pulse :as "parvus and tardus", ie, it is small or weak and rises slowly.
 Best appreciated in the carotid artery where the pulse is reduced in amplitude and delayed in
occurrence.
 The delay can be appreciated by simultaneous palpation of the apex (PMI) and the carotid artery.
 There may be :an associated carotid artery thrill or coarse vibration ("shuddering") due to the marked
turbulence of blood flow across the stenotic valve.

13. PALPITATION
 The cardiac impulse at the apex is sustained and is
initially normal in location. (However, it becomes
displaced late in the course of AS when left
ventricular failure occurs. )
 A systolic thrill :at the base of the heart (2nd ICS ),
especially during full expiration with the patient
leaning forward.

14.  S2 :soft and single since A2(due to Avclosure), is delayed and tends to occur simultaneously with
P2(due to PV closure).
 S2 may become paradoxically split when the stenosis is severe and associated with LV dysfunction .
 With increasingly severe, fixed AS, the A2 closing sound may disappear.
 The presence of a normal split S2 is the most reliable finding to exclude severe AS in adults.
 The S1 is usually N. However, an aortic ejection click, which is more commonly heard with a congenital
bicuspid valve, may be heard after S1 (when the leaflets are stiff, but still somewhat compliant and
mobile) .
 Vigorous LA contraction can lead to a S4.

15. MURMURS
 The hallmark finding is a crescendo-decrescendo ejection murmur, heard best with
the diaphragm of the stethoscope at the right upper sternal border when a patient is
sitting upright leaning forward.
 The murmur typically radiates to one or both carotid arteries and has a harsh or
grating quality.
 The intensity of the systolic murmur does not correspond to the severity of AS; rather,
the timing of the peak and the duration of the murmur corresponds to the severity
of AS. The more severe the stenosis, the longer the duration of the murmur and the
more likely it peaks at late systole.

16. • In elderly persons with calcific AS, however, the murmur may be more prominent at
the apex, because of radiation of its high-frequency components (Gallavardin
phenomenon). This may lead to its misinterpretation as a murmur of MR.
• The murmur is soft when stenosis is less severe, grows louder as stenosis
progresses, and becomes longer and peaks in volume later in systole (ie,
crescendo phase becomes longer and decrescendo phase becomes shorter) as
stenosis becomes more severe.
• As LV contractility decreases in critical AS, the murmur becomes softer and
shorter. The intensity of the murmur may therefore be misleading in these
circumstances

17. Severe Stenosis is indicated by
 Slow rising pulse
 Narrow pulse pressure
 Longer duration of murmur
 LV heave and S4 ( LVH)

18. INVESTIGATIONS
 ECG
 CHEST RADIOGRAPHY
 ECHOCARDIOGRAPHY

19. ECG

20.  LEFT ventricular hypertrophy
 Advanced cases there is
ST WAVE DEPRESSION
T WAVE INVERSION

21. CHEST X RAY
 In Early stage,
CXR may be normal or
Ascending Aorta dilatation w/ normal heart size
 In late Stage,
Cardiac enlargement
Pulmonary congestion

22.  The ascending aorta
(yellow dotted line)
leading into the arch is dilated,
whereas the distal arch and
descending aorta
(red dotted line)are normal in size.
The left heart border (blue dotted line)

23. ECHOCARDIOGRAM
Diagnostic of AS
Perform for following purposes:
 Evaluate Aortic valve morphology
 Calculate Aortic valve area
 Evaluate Left Ventricular walls thickness
 Calculate Ejection Fraction
 Estimate Aortic valve Gradient

24. Catheterization
 Catheterization is also useful in three distinct categories of patients: (1) patients with
multivalvular disease, in whom the role played by each valvular deformity should be
defined to aid in the planning of operative treatment; (2) young, asymptomatic
patients with noncalcific congenital AS, to define the severity of obstruction to LV
outflow, since operation or percutaneous aortic balloon valvoplasty (PABV) may be
indicated in these patients if severe AS is present, even in the absence of symptoms;
balloon valvotomy may follow left heart catheterization in the same sitting; and (3)
patients in whom it is suspected that the obstruction to LV outflow may not be at the
level of the aortic valve but rather at the sub- or supravalvular level

25. Classification of Aortic Stenosis

27. MANAGEMENT
 MEDICAL
 Depends upon the presenting complaints
 If LV failure,
Symptom-improving drugs
Prognosis-improving drugs
 Treating Hypertension, normalizing lipid prolife and smoking cessation has the role.

28. SURGERY
 There are 2 options for valve replacement in symptomatic
patients.
 Surgical Valve Replacement
 Transcatheter Aortic Valve Replacement (TAVR)

29.  Aortic balloon valvuloplasty is useful in
congenital aortic stenosis but is of no value in
older patients with calcific aortic stenosis

30. THANK YOU