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1. PROF.T.B.UMADEVI,MD
PROFESSOR
INSTITUTE OF INTERNAL MEDICINE
RGGGH,MMC
AORTIC VALVULAR HEART
DISEASE

2. Aortic valve- Anatomy
 Surfce area: 3-4
cm2
 3 parts:
1. Annulus
2. Leaflet
3. Commissures
 3 leaflet of equal
size separated by
3 comissures.
 No chordae
tendinae or
papillary muscle

3. Aortic stenosis
 Chronic
progressive
disease
charecterised
by obstruction
to left
ventricular
stroke volume

4. Classification
• William syndrome
• Congenital supravalvular aortic
stenosis
Supravalvular
• Senile degeneration
• Rheumatic heart disease
• Bicuspid aortic valve
Valvular
• Membranous diaphragm
• Hypertrophic obstructive
cardiomyopathy
Subvalvular

5. Senile aortic stenosis

6.  Thickening and sclerosis of valve common in 50%
population
 Sclerosis + calcificaton= stenosis
 Valve myofibroblast convert into osteoblast
resulting in calciumhydroxyappetite deposition.
 A part of atherosclerosis.

8. Symptoms
 Angina – Exertional angina due to mismatch in
myocardial oxygen demand supply ratio.
 Syncope- decreased cardiac output state
 Dyspnea- exertional due to cardiac
compensation.
 Earliest symptom: Exercise intolerence

9.  Angina – death within 5 yrs if not intervened
 Syncope- death within 3 yrs if not intervened
 Dyspnea – death within 2 yrs if not intervened
A S D- 5 3 2

10. Signs
 Pulse – pulses parvus etardus- slow rising late
peaking and late amplitude pulse.
 BP- low SBP- systolic decapitation
 Narrow pulse pressure
 Apex: displaced lateraly or normal. Heaving and
sustained apex.
 Loud single A2 in rheumatic AS and bicuspid AS
 Soft A2 in sclerotic AS

11. Murmur of AS
 Medium pitched Ejection systolic murmur
 Cresendo decresendo murmur
 Late systolic attenuation
 Rough rasping murmur(in elderly have a musical
quality- seagull murmur)
 Best heard in sitting position and end expiration
 Best in aortic area
 Gallverdin phenomenon:
 low pitched murmur Radiates to carotids
 high pitched murmur Radiates to apex
 Severity related to duration of murmur and not
intensity

13. ECG
 LVH features: v1s or v2s + v5R or v6R >35mm

14. Chest Xray

15. Trans thoracic echo
 Mean transvalvular gradient > 40 mm
 Peak flow velocity >4cm/sec
 Aortic valve area < 1cm2

16. Management – Medical
 Avoid strenous exercise
 Diuretics to be used with caution
 ACE/ARB
 Beta blockers contraindicated
 Nitrates can be used for anguna but

17. Surgical management
 Trans catheter aortic Valve replacement
 Aortic baloon valvulotomy
 Indications of surgery:
 Symptomatic AS
 Asymptomatic AS qith EF< 50%
 Asymptomatic but icreased gradient on yearly
echo
 Bicuspid valve AS
 Dobutamine stress echo positive( to differentiate
LV dysfunction due to severe aortic stenosis and
LV dysfunction due to other cause in pts with mild
AS)

18. AORTIC REGURGITATION

19. Aortic regurgitation

20. Aetiology

21. Pathophysiology

22. Symptoms
 Acute AR :
 Sudden severe
shortness of breath
 Chest pain
 Rapidly progressive
pulmonary edema,
acute decompensated
heart failure,
cardiogenic shock
Chronic AR:
Asymptomatic for 10
to 15 yrs
Palpitations
Angina‘
Exertiona dyspnea
CCF
Acute Pulonary
edema

23. Peripheral signs of AR

25. Auscultation
 Soft s1
 A2- soft- rheumatic AR/ Loud and Tambour like-
Syphillitic AR
 S3 gallop
 S4 prominent in LVH

26. Murmurs in AR
 Early diastolic murmur immediately after A2
 High pitched blowing
 Loudest at left sternal border
 Decresendo
 Best herd in end of expiration, in sitting and
leaning forward
 Duration of murmur correlates with AR
 If murmur is musical – cooing dove murmur –
signifies eversion or perforation of aortic cusp.

28. Austin Flint Murmur
 Low pitched mid diastolic rumbling murmur
 Due to :
 AR jet impinges on anterior mitral leaflet forcing it
down and reducing mitral orifice
 Turbulrnce caused by AR jet when it meets Mitral
inflow jet
 AML fluttering due to AR jet
 LV endocardial vibration due to AR jet

29. Indicators of severity in AR
 Duration of murmur
 Bisferens pulse
 S3
 Positive hills sign
 Cardiomegaly
 Austin flint murmur
 Soft A2
 Marked peripheral signs

31. Management – medical
 Vasodilators in selective cases
 Administration of sodium nitroprusside in acute
emergency leads ti increase in EF

32. Surgical management
 Valve replacement surgery
 Indications:
 Symptomatic pts
 Asymptomatic pts with EF<55%
 Asymptomatic , EF>55%, with LV dilatation
 Acute severe aortic regurgitation as in infective
endocarditis
 If undergoing CABG, surgery of ascending aorta
or other cardiac valve.

33. Thankyou