Aortic Stenosis




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Aortic Stenosis


Presentation

Sir, this patient has Aortic stenosis that is severe in nature.


My findings include:

Presence of an ejection systolic murmur heard best at the aortic area and radiates to the carotids. It is a grade 4/6 systolic murmur a/w with a systolic thrill. It is severe as there is an early ejection click a/w a long systolic murmur with delayed peaking of the murmur. I could not detect an S4 and the second heart sound is soft. There was also no paradoxical splitting of the second heart sound.

The apex beat is heaving in nature and is displaced, located at the 6th IC space at the just lateral to the mid-clavicular line.

This is associated with signs of congestive cardiac failure as evidenced by presence of bibasal crepitations, raised JVP at 3 cm with prominent V wave and bilateral pedal edema but she does not require supplemental oxygen.


Peripheral examination does not reveal any stigmata of IE. The pulse is regular at 84bpm and is anacrotic/pulsus parvus et tardus in nature. There are no features suggestive of haemolytic anaemia with no conjunctival pallor and patient is not jaundice.
I would like to complete my examination by taking the patient’s blood pressure to look for a narrow pulse pressure as well as his temperature chart. I would also like to enquire on patient’s symptoms of angina, syncope and dyspnea as these are important prognostic markers.
In summary, this patient has got aortic stenosis that is severe in nature with complication of congestive cardiac failure. There is no evidence of infective endocarditis or haemolytic anaemia. The most likely causes include Rh heart disease, calcified biscupid aortic valve or degenerative calcified aortic valves.

Questions

What are the differential diagnoses for an ejection systolic murmur?



  • AS

  • PS

  • HOCM

  • MVP/MR

  • Coarctation

How do you differentiate between them?



  • AS and PS – expiration and inspiration

  • AS and HOCM – Valsalva, squatting

  • AS and MVP – location and clicks

  • AS and Coarctation – differential pulse

What are the types of pulses associated with aortic stenosis?



  • Pulsus parvus et tardus – means low volume pulse with delayed upstroke due to a reduction in systolic pressure and a gradual decline in diastolic pressure

  • Anacrotic pulse – small volume pulse with a notch on the upstroke

What does a normal pulse volume in AS mean?


What does a palpable systolic thrill implies?



  • It means that the transvalvular gradient is > 40mmHg

What does the second heart sound indicate about the aortic stenosis?



  • Soft second heart sound means poorly mobile and stenotic valve

  • Reversed splitting means mechanical or electrical prolongation of ventricular systole; S2 is normally created by the closure of the aortic valve followed by the pulmonary valve, if the closure of the aortic valve is delayed enough, it may close after the pulmonary, creating an abnormal paradoxical splitting of S2.

  • Single second heart sound implies fibrosis and fusion of the leaflets

  • Normal second heart sound implies insignificant stenosis

What is Gallavardin phenomenon?


How can haemolytic anaemia result from aortic stenosis?



  • MAHA from severely calcified aortic valve

What are the causes of aortic stenosis?



  • Rheumatic heart disease (<60)

  • Degenerative calcification (>75)

  • Calcified biscupid (60-75, males)

What are the severity markers?



  • Early ejection click

  • Long Systolic murmur

  • Late peaking of the murmur

  • 4th heart sound

  • Paradoxical splitting of S2

  • Heaving apex beat which is displaced

  • Systolic thrill

  • Pulsus parvus et tardus

  • Narrow pulse pressure

  • Symptoms (ASD) Px

Angina 5 years

Syncope 3 years

Dyspnea (Most impt) 2 years
How do you differentiate AS from aortic sclerosis?


  • No severity signs as above

  • ESM which is localised to aortic area with a normal S2 in elderly person

How do patients present?



  • Asymptomatic and incidental finding

  • Angina

    • Increase oxygen requirement for hypertrophied LV with hypoperfusion of the subendocardial myocardium

  • Syncope

    • Cardiac arrythmias

    • Peripheral vasodilatation eg post exercise without concomitant increase in CO

    • Transient elctromechanical dissociation

  • Dyspnea

    • Implies LV dysfunction and heart failure

How would you investigate?



  • ECG – LVH with strain, 1st degree heart block, LBBB

  • CXR – Calcified aortic valve, cardiomegaly, pulmonary congestion

  • 2D echo

    • Dx

    • Severity

      • LVH, EF



Severity

Area

Transvalvular gradient

Mild

>1.5

<25

Moderate

1-1.5

25-50

Severe

<1

50-80

Critical

<0.7

>80

  • Complications eg IE

How would you manage?



        • Education

        • Medical

    • Antibiotic prophylaxis

    • Rx complications such as arrythmias and CCF (caution with antihypt to avoid reducing preload)

    • Statins may have a role in reducing calcification of the aortic valve

        • Surgical treatment

    • Indications

    • Options

      • Valve replacement (Sx of choice)

      • Valvuloplasty (for moribund patients)

What are your thoughts on a young person with AS murmur but a normal aortic valve?



  • Supravalvular stenosis

    • Can be isolated or associated with Williams syndrome

    • It is an inherited disorder, autosomal dominant, Ch 7

    • Features of elfin facies, hypertension and mental retardation with other cardiac lesions such as PS

  • Subvalvular stenosis

What abdominal condition is associated with AS?



  • Angiodysplasia of the colon (PR bleed)

What is pulse pressure?



  • Difference between systolic and diastolic pressure

  • Normal – 40mmHg

  • Wide - >60 mmHg

  • Narrow - <25mmHg

  • Note: There is no official definition but studies usually measures the pulse pressure as a continuum


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