Aortic & Pulmonary Valve Disease

Question 1

aortic valve

• describe its anatomy
• when is it open and when is it closed?
• what are the major aortic valve disorders?

Answer 1

• semilunar valve with three pocket-like cusps equal in size
• open & closed:
  
  • open during systole: allows O₂ rich blood from LV –> periphery
  • closed during diastole: prevents retrograde flow from aorta –> LV
    
    • has “mercedes benz” appearance when closed
• common disorders:
  
  • aortic stenosis
  • aortic regurgitation
  • aortic scloeris s

Question 2

what are the common causes of aortic stenosis?

Answer 2

• atherosclerosis & calficiations
  
  • becomes more common with age
• bicuspid aortic valve
• rheumatic disease

Question 3

characterize the following aortic valves

Answer 3

A. normal valve

remaining valves are stenotic from different causes: have “fish mouth” appearance

B: bicuspid valve with stenosis

C: aortic stenosis from rheumatic disease

D: calcific aortic stenosis

Question 4

what is aortic sclerosis?

Answer 4

= thickening and calcification of aortic valve

• a cause of aortic stenosis

Question 5

cogenital bicuspid valve

• pertinent etiology
• what pathologies can it lead to?
  
  • describe gross appearance seen in these pathologies.
• how should it be monitored?

Answer 5

• etiology: more common in males
• progression/pathological associations:
  
  • is present during childhood but does not cause symptoms at this time. over the years, can cause progressive calficication & stenosis
    
    • ​stenosis on scan - loss of mercedez benz sign
  • can lead to:
    
    • ascending aortic dilation & coarctation
      
      • ​dilated ascending aorta followed by coarctation (narrowing) of descending aorta
      • develops in 20-80% of pts w/ bicuspid valve
      • thus, these pts must be monitored due to risk of aortic dissection.
        
        • must consult surgery if aorta measures > 4.5 cm

Question 6

when do you consult surgery for a biscupid aortic valve patient and why?

Answer 6

if part of their aorta > 4.5 cm. this is when you have a high risk of aortic dissection

Question 7

complications of aortic stenosis?

Answer 7

• GI bleeding: due to a type of angiodysplasia called Heyde syndrome
• CHF
• MI
• stroke
• IE
• arrythmias (a-fib)

Question 8

discuss the physiological changes that occur due to aortic stenosis

Answer 8

• increased afterload due to narrow aortic valve.
• increased peak systolic pressure in LV (LV works harder)
• at first, this decreases stroke volume (LV can’t eject as much blood), which
  
  • increases end systolic volume (more blood left over in LV after ejection)
  • this eventually increases end diastolic volume as blood continues to accumulate in LV
    
    • stroke volume ultimately gets back to normal

Question 9

the physiological changes tha toccur during aortic stenosis lead to what pathological changes?

Answer 9

• as LV pressure increases due to accumulating blood in left ventricle that it can’t pump out, the LA pressure must increase so it can keep filling the LV.
  
  • LA hypertrophies & hypercontracts
    
    • ​eventually, this causes
      
      • pulmonary congestion
      • pulmonary dedma

Question 10

what are the key symptoms in the classical presentation of aortic stenosis?

Answer 10

• dysnpea (due to congestive heart failure)
• angina: due to ischemia due to overworked heart and possibly also CAD
  
  • constantly high aortic pressure can damage the coronary arteries, worsening the O2 supply/demand balance in the heart
  • worse during exertion
• syncope:
  
  • ​likely due to inability of heart to effectively perfuse the body due to stenoic artery (systemic hypoperfusion)
  • worse during exertion

Question 11

• exam findings of in assessment of aortic stenosis
  
  • what will you hear on ascultation?

Answer 11

• ascultations
  
  • murmurs:
    
    • harsh crescendo-descresendo murmur heard during systole (due to turbulent flow)
      
      • generally heard at right upper sternal border (remember all physicians take money)
        
        • in gallavardin phenomomen - can be heard at the apex
      • is transmitted to the carotids
      • fluxuates in loudness:
        
        • decreases with standing
        • increases with squatting
  • S3, S4 sound can be heard
  • AI (apical impulse) displaced inferior-laterally
• other findings:
  
  • in late disease: prominent v-wave may appear in jugular vein

Question 12

what is the standard diagnostic test for aortic stenosis and what does it show?

Answer 12

• echocardiogram
  
  • shows valvular area (thus, degree of stenosis)
    
    • normal aortic valve area: 3-4 cm²
  • shows LV function

Question 13

other than echocardiogram, what diagnostic tests are used in the assessment of aortic stenosis?

• in what circumstances are they used?
• what might they show?

Answer 13

• EKG - if suspected arrthymia. could show
  
  • LVH
  • LBBB
  • a-fib
• stress tests - only done in asymptomatic patients if we suspect they also have CAD (coronary artery disease)
• CT/MRI of heart - done prior to valve replacement

Question 14

treatment of aortic stenosis

Answer 14

• medical intervention can only manage the complications resulting from AS
  
  • ​for CHF: give diuretics & other anti-HTN
  • if they have a-fib: anticoagulants
    
    • Eliquis
    • Xarelto
  • give tx for endocarditis
• consider surgical treatment

Question 15

what are the types of surgical treatment that can be done for aortic stenosis?

• what are the pros/cons of each treatment?

Answer 15

• aortic valve replacement = gold standard
  
  • choose what surgery to do based on degree of risk:
    
    • TAVR
    • open aortic valve repair: do for patients with comorbid multivessel CAD who will require bypass surgery & will thus be having open surgery- surgies done at the same time
  • which valves to used?
    
    • same as with other valvular replacements:
      
      • mechanical - lifelong duration, require anticoagulants
        
        • for long term anti-coagulatation:
          
          • DOAC
          • VKA
        • if pt also has atrial fibrillation:
          
          • Eliquis
          • Xarelto
      • bioprosthetic - more temporary use, dont require anti-coagulants
• balloon valvuloplasty
  
  • uses: to provide s_hort time symptom_ mangement
  • cons:
    
    • can cause aortic regurgitation to some degree (not used much anymore)

Question 16

what anti-cougulants are for patients who recieve an mechanical valve in aortic valve replacement?

Answer 16

for long term anti-coagulatation:

• DOAC
• VKA

if pt also has atrial fibrillation:

• Eliquis
• Xarelto

Question 17

what are the methods of doing a TAVR procedure and which one is the most common?

Answer 17

transfemoral is the most common

Question 18

what is aortic regurgitation

Answer 18

• when aortic valve leafelets do not close properly during diastole

Question 19

physiology of aortic regurgitation

Answer 19

• aortic valve isn’t fully closed in during diastole like it should be. during diastole, back-flow from aorta into LV adds to the pre-load in the LV that came from the LA, inceasing stroke volume. this results in
  
  • increased LV end-diastolic volume & pressure
  • increased increased stroke volume
• in very late aortic regurgitation:
  
  • ​LV failure can occur.
    
    • ​​at this point, stroke volume plummets

Question 20

• acute and chronic AR clinical presentations

Answer 20

• acute AR
  
  • like with acute MR- severe hypotension/possible shock
  • in addition, these patients are gravely ill appearing
• chronic AR
  
  • exertional dyspnea
  • paroxysmal exertional dyspnea
  • angina
  • palpitations
  • patients complain of umcomfortanle awareness of heart beat, particularly when laying down

Question 21

• exam findings of aortic stenosis
  
  • what is seen on ascultation?
  • what about the rest of the physical exam?

Answer 21

• ascultation
  
  • murmurs you might hear:
    
    • high frequency diastolic mumur at right after S2 (or A2, closure of aortic valve)
      
      • heard at 3-4th intercostal space at sternal border
      • vs the l_ow frequency_ diastolic in late diastole seen in mitral stenosis
      • more severe murmur = more severe AR
      • there may also be a “cooing” dove sound may indicate cusp perforation
    • austin flint murmur: mid-diastolic rumble​​
      
      • this murmur is heard at the APEX
• other findings:
  
  • LARGE PULSE PRESSURES (systolic - diastolic)
    
    • high sysolic
    • low diastolic
  • enlarged, forceful displaced apical inpulse inferior laterally
    
    • (you also see a inferior-lateral displaced AI in aortic stenosis)

Question 22

exam findings seen with aortic regurgitation

Answer 22

Question 23

• what diagnostic tests should you get for aortic regurgitation and what key things could they show you?

Answer 23

• ECG
  
  • left axis deviation
  • bundle branch blocks
• echocardiography (standard)
  
  • shows valve function & diameter as always
• CXR
  
  • might show massive LV dilation - called “cor bovinum”

Question 24

treatment for acute aortic regurgitation?

Answer 24

• depends on other factors:
  
  • if BP isnt too low: give nitroprusside or hydralazine
  • is aortic dissection in the cause: IV beta blockers + lower BP
  • if pt is hypotensive: IV dopamine or dobutamine
• do surgery definitively.

Question 25

treatment for chronic aortic regurgitation

Answer 25

• pharmaceutical intervention not as specific as it is for acute regurgitation:
  
  • ACEs/ARBs
  • if marfan’s syndrome: ACEs/ARBS + beta blockers
  • if pt has systolic heart failure: treat with HF regimen
    
    • diuretics (furosemide)
    • ACE inhibitors
    • b blocker (carvedilol)
    • salt restriction
• do valve replacement if:
  
  • LVEV < 50% and end systolic diameter rises to > 50 mm

Question 26

what is noonan syndrome? how is it related to valvular disease?

Answer 26

• genetic disorder presenting with short stature and unusual facial charateristics. can cause pulmonary stenosis

Question 27

• diagnostics tests for pulmonic stensosis and what they might be show?

Answer 27

• EKG:
  
  • LBBB (more common in noonan syndrome)
• CXR
  
  • may show post stenotic dilation of pulmonary artery
• echocardiogram
  
  • thick, doming leafelets

Question 28

pulmonic stenosis treatment

Answer 28

• mild disease observation
• severe disease treated with percutaneous balloon valvotomy
  
  • ​note that this is NOT recommended in mitral/tricuspid valve repairs

Question 29

what is pulmonic regurgitaion

Answer 29

Dilation of the valve ring or dilation of pulmonary artery from primary or secondary pulmonary hypertension (most common cause)

Question 30

exam findings of pulmonary regurgitation

• ascultation?
• other findings

Answer 30

• auscultation
  
  • low pitched decresendo diastolic murmur
    
    • heard at 3-4 intercostal space
  • possible split S2
  • if pulmonary arterial pressure > 55 (severe pulmonary HTN)
    
    • Graham steel murmur: high pitched blowing, descrendo beginning immediatley after P2 (pulmonic closure)
      
      • increases with inspiration
      • decreases with valvasa strain

Question 31

what will an EKG of pulmonic regurgitation generally show?

Answer 31

• genearlly, the EKG is normal
• however, if there are abnormalities, they are likely the following:
  
  • rhythm rate of 65 bmp
  • Peaked P waves in lead II
    
    • (also seen in tricuspid stenosis seen in carcinoid heart)
  • right axis deviation (- in lead I, + in lead aVF)
  • dominant R wave in V1
  • deep S waves in V6
  • inverted T waves in lead II, III, avFR, V1-V3 if there is RV strain present

Question 32

treatment of pulmonic regurgitation

Answer 32

• directed at underlying disease process.
  
  • in other weirds, treat the right sided heart failure
• surgery is RARELY indicated