14 ) Aortic valve diseases (acquired). Flashcards
the normal parameters of the aortic valve ?
aortic valve area = 3.0 -4.0 cm2
aortic valve pressure gradient = less than 10mmhg
pulmocapillary wedge pressure (estimate of left atrial pressure) = 12mmhg
give the classification of aortic stenosis disease etiology and relate that to the location ?
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
what is the definition of aortic valve stenosis ?
aortic valve area less than 3cm2
what are the signs and symptoms of aortic stenosis ?
dyspnea - expecially when you exert yourself
angina pectoris = severe
syncope = severe
in physical examination what do you find for aortic valve stenosis ?
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
what findings do you see in aortic stenosis for auscultation ?
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
what will confirm the diagnosis for aortic stenosis ?
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)
based on echocardiographic doppler criteria how do we classify AHA aortic stenosis
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
Exercise stress testing is contraindicated in patients with?
severe symptomatic AS (stage D).
what are the contraindications of drugs in moderate to severe aortic stenosis ?
ACE inhibitors
ARB
what are the managmnet of aortic stenosis ?
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
what is the managmnet of aortic stenosis with rheumatic heart disease ?
should receive secondary prophylaxis such as penicillin G or benzyslpenacillin
or sulfadiazine
in dental procedures consider prophylaxis for infective endocarditis
what are the indications for aortic valve replacement / in aortic stenosis
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 !
what are the different types of aortic valve replacement surgeries ?
surgical aortic valve replacement
trans catheter aortic valve replacement
percutaneous ballon valvuloplasty
what are the different types of aortic valve replacement
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.
who are transcatheter avr indicated for ?
high surgical risk and predicted survival of over 12 months
cardiogenic shock
electrical instability
acute decompensation with respiratory failure
after valve replacements what is the treatment management ?
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
what type of drugs are contraindicated in post management of mechanical aortic valve replacement
direct oral anticoagulants
eg dabigatran , rivaroxaban
what is the classification in etiology of aortic insufficiency ?
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)
what are clinical features in acute aortic insufficiency ?
Sudden, severe dyspnea
Pulmonary edema
Symptoms related to underlying disease (e.g., fever due to endocarditis, chest pain due to aortic dissection)
what are clinical features in chronic aortic insufficiency ?
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
in physical examination what can we see with aortic valve regurgitation
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
in auscultation what do we find for aortic regurgitation ?
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
what are the confirmatory diagnosis for aortic regurgitation ?
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
what are the indication for high aortic insufficiency ?
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
what are the pharmacological treatment for aortic insufficiency ?
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
indication for surgery in aortic valve regurgitation ?
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
