5.7 Aortic Stenosis

Question 1

A 70-year-old woman with aortic stenosis presents for an open aortic valve
replacement (AVR).
a) What are the three most common aetiological causes of aortic stenosis?

Answer 1

● Congenital (bicuspid valve).

● Rheumatic fever.

● Calcification (sclerosis).

Question 2

b) What are the main pathophysiological factors responsible for deterioration in a patient with aortic stenosis?

Answer 2

● Left ventricular outflow obstruction.

● Concentric LV hypertrophy.

● LV diastolic dysfunction.*

● Myocardial ischaemia.

● Fixed stroke volume.*

● LV failure.

Question 3

c) Which specific symptoms may be used in assessing the progression of this woman’s disease and correlate directly with 50% mortality?

Answer 3

● Angina — 5 years.

● Syncope — 3 years.

● Dyspnoea (congestive heart failure) — 2 years

Question 4

d) Which specific cardiac investigations would you ask for in assessing this women preoperatively?

Answer 4

● ECG — LV hypertrophy, arrhythmias (especially AF).

● Echocardiography —
valve area, aortic root pathology, pathology in
other valves, ventricular function.

● Angiography —
coronary pathology, LV angiogram (function).

Question 5

e) Give values for the peak aortic flow velocity, mean pressure
gradient and valve area that would indicate that this woman
has severe aortic stenosis.

Answer 5

● Peak aortic flow velocity >4m/s.

● Mean pressure gradient >40mmHg.

● Valve area <1cm2.

Question 6

f) What would be your haemodynamic goals for the perioperative
management of this patient?

Answer 6

● Maintain myocardial oxygen delivery.

● Avoid tachycardia (adequate diastolic perfusion).

● Maintain contractility.

● Optimal preload.

● Treat arrhythmias and maintain sinus rhythm.