14 ) Aortic valve diseases (acquired).

Question 1

the normal parameters of the aortic valve ?

Answer 1

aortic valve area = 3.0 -4.0 cm2

aortic valve pressure gradient = less than 10mmhg

pulmocapillary wedge pressure (estimate of left atrial pressure) = 12mmhg

Question 2

give the classification of aortic stenosis disease etiology and relate that to the location ?

Answer 2

SUPRAVALVULAR
congenital : membrane , coarctation

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VALVULAR

congenital:
bicuspid - predisposition to calcification
unicuspid

acquired :
degenerative - calcification and fibrosis (sclerosis)
rheumatic

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SUBVALVULAR

congenital :
fibromusclar ridge
hypertrophic obstructive CMP

Question 3

what is the definition of aortic valve stenosis ?

Answer 3

aortic valve area less than 3cm2

Question 4

what are the signs and symptoms of aortic stenosis ?

Answer 4

dyspnea - expecially when you exert yourself

angina pectoris = severe

syncope = severe

Question 5

in physical examination what do you find for aortic valve stenosis ?

Answer 5

decrease pulse pressure

pluses parvus et tarsus - the pulse is late relative to the contraction of the heart
parvus - it also weak and small

patient tae deep breath and if the murmur gets louder its a diastolic murmur

palpable systolic thrill over bifurcation of carotid

Question 6

what findings do you see in aortic stenosis for auscultation ?

Answer 6

in 2nd intercostal space right side - aortic side
LATE SYSTOLIC MURMUR
harsh crescendo decrescendo

Rhomb-shaped, the later the peak, the more severe is the stenosis

ALWAYS AUSCULTATE THE CAROTID ARTERY - it radiates
also radiates to APEX

before the systolic murmur there early systolic ejection click - opening of the stenotic valve

• s2 soft
  S4 best heard at apex
  by the reduced LV compliance due to the developing severe hypertrophy

Cardiac apical beat is shifted to the left and downwards

correctly identify if heart sound is sytolic or diastolic palpate the pulse at the carotid artery - first heart s1 sound occur simultaneously with carotid pulse

Question 7

what will confirm the diagnosis for aortic stenosis ?

Answer 7

Echocardiography –
M-mode,
2D,
CW- Doppler

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TTE - for operation planning

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ECG - sign of left ventricular hypertrophy
using sokolow lyon index

look at the R wave more than 11mm

Left ventricular hypertrophy (LVH): SV1 /2 + RV5 /6 ≥ 3.5 mV or 35mm

one big ox is 5mm

Right ventricular hypertrophy (RVH): RV1 or 2 + SV5 or 6 ≥ 1.05 mV or 10.5mm

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Chest x-ray: Used to assess for pulmonary edema or other causes of dyspnea. [2]
Visible calcifications within the aortic valve may indicate more severe disease. [3]
Narrowing of retrocardiac space (lateral view)

Question 8

based on echocardiographic doppler criteria how do we classify AHA aortic stenosis

Answer 8

stage A
at risk

aortic valve area = 3-4cm2

transaortic velocity = <2m/s

mean aortic gradient =<10mmhg

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Stage B
Progressive AS

Mild:
<3 cm2
<3 m/s
<20 mm Hg

Moderate
<1.5 cm2
<4 m/s
<40 mm Hg

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Stage C1
Asymptomatic severe AS (LVEF norma 50-70l)

Stage C2 Asymptomatic severe AS (LVEF < 50%)

Stage D
Symptomatic severe AS

≤ 1.0 cm2
≥ 4.0 m/second
≥ 40 mm Hg

Question 9

Exercise stress testing is contraindicated in patients with?

Answer 9

severe symptomatic AS (stage D).

Question 10

what are the contraindications of drugs in moderate to severe aortic stenosis ?

Answer 10

ACE inhibitors

ARB

Question 11

what are the managmnet of aortic stenosis ?

Answer 11

acute decomepnsated heart failure
loop diuretics with caution because patinets are very suscopetible to hyotension
consider vasodilators such as nitroprsside

in cardiogenic shock
iv fluid managemnet
dobutamine and dopamine
consider bridging device - intraaortic balloon pump
percutenaous balloon valvulopasty - but in effective in adults

atrial fib - managmnet

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chronic cases :
there is mechanical valve replacement lasts longer
there is prosthetic valve replacemnet
transcather aortic valve repacemnet - highly sympotmatic and high risk to surgery
hemodynimaclly snsatble - acute decemponesation hf
cardiogenic hsock
electrical instablity

Question 12

what is the managmnet of aortic stenosis with rheumatic heart disease ?

Answer 12

should receive secondary prophylaxis such as penicillin G or benzyslpenacillin
or sulfadiazine

in dental procedures consider prophylaxis for infective endocarditis

Question 13

what are the indications for aortic valve replacement / in aortic stenosis

Answer 13

symptomatic - stage d AS
asymptomatic patients with reduced LVEF such as stage C2 AS

presence of dyspnea on exertion , angina pectoris or syncope is an indication for high res and surgery !

Question 14

what are the different types of aortic valve replacement surgeries ?

Answer 14

surgical aortic valve replacement

trans catheter aortic valve replacement

percutaneous ballon valvuloplasty

Question 15

what are the different types of aortic valve replacement

Answer 15

Mechanical valves
tissue valves

mechanical valves last longer than tissue valves. They are less likely to wear out or break down. If you are age 50 or younger, a mechanical valve may be a good choice. That’s because you are young enough that you probably will live longer than a tissue valve might last.

Question 16

who are transcatheter avr indicated for ?

Answer 16

high surgical risk and predicted survival of over 12 months

cardiogenic shock

electrical instability

acute decompensation with respiratory failure

Question 17

after valve replacements what is the treatment management ?

Answer 17

mechanical valves with no risk factors to increase thromboembolism

antiplatelte drug with Vit K antagonist
such as ASA and warfarin

duration of therapy is lifelong

target inr 2.5-3.5

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mechanical valve with 1 or more risk factors for thromboembolism

or older gen mechanical vales

the same as above ^

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bioprosthetic valve with low risk of bleeding

anti-platelet such as ASA with VKA such as warfarin

target INR is 2.5
but range of 2-3

duration
anti platelet such as aspirin lifelong

VKA
3-6 months post surgical avr
atleast 3 months in post TAVR

Question 18

what type of drugs are contraindicated in post management of mechanical aortic valve replacement

Answer 18

direct oral anticoagulants

eg dabigatran , rivaroxaban

Question 19

what is the classification in etiology of aortic insufficiency ?

Answer 19

Acute AR
Infective endocarditis

Aortic dissection (ascending aorta)

Chest trauma

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Chronic AR
Congenital bicuspid valve

Rheumatic heart disease: in developing countries

Others:
Rheumatoid arthritis Ankylose spondylitis Lues

Distortion or dilation of the ascending aorta and aortic root due tp connective tissue disorders (e.g., Marfan syndrome, Ehlers-Danlos syndrome
Tertiary syphilis)

Question 20

what are clinical features in acute aortic insufficiency ?

Answer 20

Sudden, severe dyspnea

Pulmonary edema

Symptoms related to underlying disease (e.g., fever due to endocarditis, chest pain due to aortic dissection)

Question 21

what are clinical features in chronic aortic insufficiency ?

Answer 21

May be asymptomatic for up to decades despite progressive LV dilation

Palpitations

Symptoms of left heart failure
Exertional dyspnea
Angina 
Orthopnea
Easy fatigability
Syncope

Symptoms of wide pulse pressure
head pounding,
bobbing of the head in synchrony with heartbeats- DE Musset sign

Question 22

in physical examination what can we see with aortic valve regurgitation

Answer 22

High pulse pressure eg150/50
Water hammer pulse of peripheral arteries (radial pulse)
characterized by rapid upstroke and downstroke
e.g., “bounding pulse”

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known Corrigan’s pulse in the carotid artery

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Visible capillary pulse (Quincke sign)

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Nodding of the head with each pulse

Question 23

in auscultation what do we find for aortic regurgitation ?

Answer 23

aortic regurgitation is head best along the left parasternal border at third and 4th intercostal space = erb point

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High-pitched, blowing, decrescendo early diastolic murmur

increasing its intensity when squatting or handgrip - increases the after load

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S3

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Auscultation on a. femoralis:  double sound of Traube
 double murmur of Durozier

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AR due to aortic root disease (e.g., aortic dissection): best heard along the right sternal border

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Austin Flint murmur
In more severe stages, possibly a harsh, crescendo-decrescendo mid-systolic murmur that resembles aortic stenosis

Question 24

what are the confirmatory diagnosis for aortic regurgitation ?

Answer 24

Transthoracic echocardiogram (TTE)
- dilated aorta ad ventricles
Fluttering of anterior mitral valve leaflet

Transesophageal echocardiogram (TEE): indicated if suboptimal or nondiagnostic TTE

ECG
signs of left ventricular hypertrophy

chest X ray
prominent aortic root or arch
and enlarged silhouette of heart

Question 25

what are the indication for high aortic insufficiency ?

Answer 25

Presence of peripheral vascular signs

 Systolic-diastolic difference in BP (pulse pressure) >
80mmHg

 Diastolic arterial pressure < 60mmHg

 Angina pectoris

 LVEDD > 66 mm

 Doppler Еcho - > ІІІ degree regurgitation

 PHT (pressure half-time) of the aortic regurgitation flow <250 msec

Question 26

what are the pharmacological treatment for aortic insufficiency ?

Answer 26

pharmacologcal
unline other hr slowing does no bring any benfit but increases time of regirgitation - so avoid beta blockers
physical activity without excessivestraining reduces regurgitation

treatmet for left sided heart failure :
loop diuretics ,thiazides
ACEI

peripheral arteria; and venous vasodilators

surgical
MOSTLY aortc valve replacemnt with long term antcogualtton

Question 27

indication for surgery in aortic valve regurgitation ?

Answer 27

Symptomatic patients with acute severe AR
Urgent aortic valve replacement irrespective of the cause
 medications do not help!!!

Asymptomatic patients with:
Chronic severe AR and EF < 50%

Left ventricular systolic diameter > 50 mm

with long-term anticoagulation therapy for mechanical valve