Aortic Stenosis

1. Aortic Stenosis
K. Kavindya M. Fernando
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2. Aortic stenosis
• Chronic progressive disease
• Produces obstruction to the L/ ventricular
SV
• Leading to symptoms of
– Chest pain
– Breathlessness
– Syncope
– Pre-syncope
– fatigue
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3. Causes
• Aortic Valve stenosis
• Calcific aortic valvular disease (CAVD)
• Bicuspid aortic valve (BAV)
• Rheumatic fever
• Other causes of valvular stenosis
• Valvular aortic stenosis
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4. Causes
• Aortic Valve stenosis
– Calcific stenosis of the trileaflet aortic
valve
– Stenosis of congenital bicuspid valve
– Rheumatic aortic stenosis
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5. Causes
• Calcific aortic valvular disease (CAVD)
– Common cause of aortic stenosis
– Mainly occurs in elderly
– Inflammatory process involving macrophages &
T lymphocytes
– with initially thickening of the subendothelium
with adjacent fibrosis
– Risk factors
• Age, male gender, lipoprotein a, LDL, hypertension,
diabetes, smoking
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6. Causes
• Bicuspid aortic valve (BAV)
– Commonest form of congenital heart
disease
– Associated with aortic coarctation, root
dilatation, potentially aortic dissection
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7. Causes
• Other causes of valvular stenosis
– Chronic kidney disease
– Paget’s disease of bone
– Previous radiation exposure
– Homozygous familial hypercholesterlemia
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8. Causes
• Other causes of obstruction to left
ventricular emptying
– Supraventricular obstruction
• Congenital fibrous diaphragm above the aortic valve
• Associated with mental retardation & hypocalcaemia
(William’s syndrome)
– Hypertrophic cardiomyopathy
• Septal muscle hypertrophy,
• Obstructing left ventricular outflow
– Subvalvular aortic stenosis
• Fibrous ridge or diaphragm is situated immediately
below the aortic valve
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9. Causes
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10. Pathophysiology
• Obstructed left ventricular emptying
– Increased ventricular pressure
– Compensatory left ventricular hypertrophy
• Results in
– relative ischemia of the L/ ventricle
myocardium
– Consequent angina
– Arrhythmias
– L/ ventricular failure
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11. Pathophysiology
• Obstruction is more severe on exercise
• Normal exercise : CO increases
• When there is severe narrowing of aortic
valve CO hardly increases
• BP falls
• Coronary ischemia worsens
• Myocardium fails
• Cardiac arrhythmias develops
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12. Symptoms
• Usually no symptoms until aortic
stenosis is moderately severe (reduced
to 1/3rd of normal size)
• Exercise induced sycope
• Angina
• Dyspnea
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13. Signs
• Pulse: sinus rhythm, low volume,
slow rising
• Aortic area: Systolic trill
• Apex: Not displaced, sustained
• Sounds: Ejection click, Soft A2,S4
• Murmurs: systolic, low pitched,
ejection, radiating to
carotids
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14. Signs
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15. Signs : precordial palpation
• Apex beat not displaced
• Pulsation is sustained and obvious
• A double impulse is sometimes felt
– because the fourth heart sound or
– atrial contraction (‘kick’) may be palpable.
• A systolic thrill may be felt in the aortic
area.
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16. Signs : precordial palpation
• Apex beat not displaced
• Pulsation is sustained and obvious
• A double impulse is sometimes felt
– because the fourth heart sound or
– atrial contraction (‘kick’) may be palpable.
• A systolic thrill may be felt in the aortic
area.
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17. Signs : Auscultation
• Ejection- systolic murmur
• Usually diamond shaped (crescendo-
decrescendo)
• Murmur is longer – severe cases
• Rough in quality
• Best heard in aortic area
• Radiates into carotids and to precordium
• Severe cases murmur- inaudible
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18. Signs : Auscultation
• Other findings
– Systolic ejection click
• Unless the valve has become immobile &
calcified
– Soft & inaudible aortic 2nd heart sound
• When aortic valve becomes immobile
– Reversed splitting of the 2nd heart sound
• Splitting on expiration
– Prominent 4th heart sound
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19. Physical signs
S1 S2 S1
S2
Mild-Moderate Severe

20. Investigations
• Chest X-ray
• ECG
• Echocardiography
• Cardiac catheterization
• Cardiac magnetic resonance and cardiac
CT
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21. Investigations
• Chest X-ray
– Relatively small heart
– With prominent dilated ascending aorta
– Due to turbulent blood flow above the
stenosed aortic valve produced “ post-
stenotic dilation”
– Aortic valve may be calcified
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22. Investigations
• ECG
– Left ventricular hypertrophy
– Left atrial delay
– L/ ventricular ‘strain’ pattern- due to
pressure overload
• Depressed ST segment,
• T wave inversion (I, AVL, V5, V6)
• (Leads orientated towards the L/ ventricle)
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23. Treatment
• Symptoms are good index of severity
• All symptomatic patients : aortic valve
replacement
• Precutaneous valve replaacement.
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