Aortic stenosis
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This document discusses aortic stenosis and aortic regurgitation. It defines aortic stenosis as a narrowing of the aortic valve opening, with common causes being a bicuspid aortic valve, calcification, or rheumatic heart disease. Symptoms include angina, syncope, and dyspnea. Diagnosis involves echocardiography. Treatment options are balloon valvuloplasty or valve replacement. Aortic regurgitation is defined as retrograde blood flow through the aortic valve during diastole. Common causes are rheumatic fever, hypertension, or a bicuspid valve. Symptoms progress from palpitations to dyspnea. Physical exam may reveal a wide pulse pressure.
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Aortic stenosis
- 3. Normal aortic valve surface area is 03 – 04 cm2 Narrowing of aortic orifice is called aortic stenosis
- 4. Etiology • Congenitally Abnormal Bicuspid Aortic valve • Senile Degenerated or calcified Aortic valve • Rheumatic heart Disease
- 5. Aortic Stenosis Mimickers Subvalvular Stenosis + Hypertrophic Cardiomyopathy + Subvalvular Membrane Supravalvular Stenosis + William Syndrome (hypercalcemia, growth failure and mental retardation)
- 8. History Exertional Angina Exertional Syncope Dyspnoea (Heart Failure) Fatigue
- 9. Angina Syncope It may occur due to exertion and relieve by rest. Sometimes, Coronary artery disease may coexist. It occurs due to peripheral vasodilatation but unchanged cardiac output It occurs due to exertion.
- 10. Physical Examination Pulse: low volume slow rising Narrow pulse pressure Apex beat may shift to left (down ward & outside due to LVH ) Heaving apex Ejection systolic murmur rough character best heard in Rt. 2nd ICS (AA) Prominent S4
- 13. Chest X Ray In Early stage, CXR may be normal In late Stage, Cardiac enlargement Two-dimensional Echocargiography • Diagnostic of AS
- 14. Treatment BP control It patient is symptomatic balloon valvotomy It valve is damaged or calcified AV Replacement
- 16. Aortic Regurgitation: overview AR is a condition due to inadequate closure of the aortic valve leaflets leading to abnormal retrograde flow of blood through the aortic valve during cardiac diastole. It can be induced either by damage to and dysfunction of the aortic valve leaflets or by distortion or dilatation of the aortic root and ascending aorta In the developing world, the most common cause of AR is rheumatic heart disease. However, in developed countries, AR is most often due to aortic root dilation or a congenital bicuspid aortic valve .[1]
- 17. Causes of Aortic Regurgitation Leaflet abnormalities Aortic root or ascending aorta Rheumatic fever Systemic hypertension Endocarditis Aortitis (eg, syphilis) Trauma Bicuspid aortic valve Ankylosing spondylitis Trauma/ Dissecting aneurysm Marfan syndrome/ EDS Inflammatory bowel disease AR is seen more commonly in men than in women.
- 18. Pathophysiology of aortic regurgitation Aortic regurgitation LV volume LV mass LV dysfunction LV failure stroke volume Systolic BP Diastolic BP Wide pulse pressure hyperdynamic circulation
- 19. Palpitation Initial symptom due to vigrous contraction of volume overload LV Angina Less common as C/F AS Dyspnoea Initially on exertion PND Clinical history
- 20. Physical finding Pulse Very good volume & wide pulse pressure Rapid rise & collapse with markedly ed pulse pressure (water hammer pulse / Corrigan pulse)
- 21. Findings are a/w hyperdynamic pulse deMusset's sign A head bob occurring with each cardiac cycle Mueller's sign Systolic pulsations of the uvula. Landolfi sign Change in size of pupil with each beat Quincke's pulses visible Capillary pulsations in the nailbeds after holding the tip of the nail. Traube's sign A pistol shot murmur (systolic and diastolic sounds) heard over the femoral arteries. Duroziez's sign A systolic and diastolic bruit heard when the femoral artery is partially compressed.to and fro murmur Hill's sign Normal BP in LL > UL Normal difference is up to 20 In AR the difference > 20
- 22. Auscultation Early diastolic murmur Best heard LSB left 3rd /4th ICS with patient sitting & leaning forward
- 23. Lab investigation CXR Cardiomegaly ECG LV hypertrophy Echo Confirm the diagnosis
- 24. Treatment Medical treatment (for heart failure) - Diuretics, Digoxin, salt restriction - Vasodilators - Endocarditis prophylaxis Surgical treatment (in severe cases) AVR .
Editor's Notes
- The aortic valve is the valve located between the left ventricle of the heart and the aorta, the largest artery in the body, which carries the entire output of blood to the systemic circulation.
- Patient is asymptomatic for many years
- AR is a condition due to inadequate closure of the aortic valve leaflets leading to abnormal retrograde flow of blood through the aortic valve during cardiac diastole.
- AR may be caused by either valvular or aortic root pathology. Valvular abnormalities that may result in AR include bicuspid aortic valve (the most common congenital cause), rheumatic fever, infective endocarditis, collagen vascular diseases, and degenerative aortic valve disease. Abnormalities of the ascending aorta, in the absence of valve pathology, may also cause AR, such as may occur with longstanding uncontrolled hypertension, Marfan syndrome, idiopathic aortic dilation, syphilitic aortitis, giant cell arteritis, Takayasu arteritis, ankylosing spondylitis, Whipple disease, and other spondyloarthropathies. The absence of a wide pulse pressure and of the characteristic arterial auscultatory signs of chronic AR in patients with acute AR is thought to be due to the much higher LV end-diastolic pressure (LVEDP) in the acute form. The acute development of a severe aortic valvular leak causes a much higher LVEDP in the normal-sized LV of patients with acute AR. Patients with chronic AR commonly have a dilated LV with increased compliance capable of accommodating large blood volumes without a significant rise of LVEDP.
- Sherman sign ; prominently located and palpated dorsalis pedis pulse Landolfi sign: alternating constriction and dilatation of pupil Duroziez sign: systolic portion of murmur was caused by forward flow into the lower extremity and the diastolic segment was caused by aortic regurgitation towards the heart. Seagull murmur: it is murmur with musical qualities such as that heard occasionally in aortic insufficiency. A sea gull cry murmur is defined as a murmur imitating the cooing sound of a seagull.this type of murmur is typically characterised by a music timbre and a high frequency and may occur as a result of various valve disease.it is usually described as a sign of tight calcific aortic stenosis when the murmur high frequency components are transmitted to the lower left sternal border and the cardiac apex during most of the systole (gallavardin phenomenon).in this condition,the typical harsh timbre of the ejective murmur tends to assume a musical high pitched quality ,resembling that of mitral regurgitation which may be reminiscent of the cry of a seagull. A protodiastolic murmur with similar characteristics ,typically in decrescendo ,may occur in severe AR particularly when the flow presents high velocities. However, a seagulls cry murmur may also be the sign of MR or prolapse. Similarly the muscial and holosystolic sound reflects the presence of high frequency components due to high velocities of reflow.