Aortic & Pulmonary Valve Disease Flashcards
1
Q
aortic valve
- describe its anatomy
- when is it open and when is it closed?
- what are the major aortic valve disorders?
A
- 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
2
Q
what are the common causes of aortic stenosis?
A
- atherosclerosis & calficiations
- becomes more common with age
- bicuspid aortic valve
- rheumatic disease
3
Q
characterize the following aortic valves
A
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
4
Q
what is aortic sclerosis?
A
= thickening and calcification of aortic valve
- a cause of aortic stenosis
5
Q
cogenital bicuspid valve
- pertinent etiology
- what pathologies can it lead to?
- describe gross appearance seen in these pathologies.
- how should it be monitored?
A
- 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
-
ascending aortic dilation & coarctation
- is present during childhood but does not cause symptoms at this time. over the years, can cause progressive calficication & stenosis
6
Q
when do you consult surgery for a biscupid aortic valve patient and why?
A
if part of their aorta > 4.5 cm. this is when you have a high risk of aortic dissection
7
Q
complications of aortic stenosis?
A
- GI bleeding: due to a type of angiodysplasia called Heyde syndrome
- CHF
- MI
- stroke
- IE
- arrythmias (a-fib)
8
Q
discuss the physiological changes that occur due to aortic stenosis
A
- 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
9
Q
the physiological changes tha toccur during aortic stenosis lead to what pathological changes?
A
- 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
-
eventually, this causes
-
LA hypertrophies & hypercontracts
10
Q
what are the key symptoms in the classical presentation of aortic stenosis?
A
- 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
11
Q
-
exam findings of in assessment of aortic stenosis
- what will you hear on ascultation?
A
- 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
- generally heard at right upper sternal border (remember all physicians take money)
-
harsh crescendo-descresendo murmur heard during systole (due to turbulent flow)
- S3, S4 sound can be heard
- AI (apical impulse) displaced inferior-laterally
- murmurs:
- other findings:
- in late disease: prominent v-wave may appear in jugular vein
12
Q
what is the standard diagnostic test for aortic stenosis and what does it show?
A
- echocardiogram
- shows valvular area (thus, degree of stenosis)
- normal aortic valve area: 3-4 cm2
- shows LV function
- shows valvular area (thus, degree of stenosis)
13
Q
other than echocardiogram, what diagnostic tests are used in the assessment of aortic stenosis?
- in what circumstances are they used?
- what might they show?
A
- 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
14
Q
treatment of aortic stenosis
A
- 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
15
Q
what are the types of surgical treatment that can be done for aortic stenosis?
- what are the pros/cons of each treatment?
A
-
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
- for long term anti-coagulatation:
- bioprosthetic - more temporary use, dont require anti-coagulants
- mechanical - lifelong duration, require anticoagulants
- same as with other valvular replacements:
- choose what surgery to do based on degree of risk:
-
balloon valvuloplasty
- uses: to provide s_hort time symptom_ mangement
- cons:
- can cause aortic regurgitation to some degree (not used much anymore)
17
Q
what are the methods of doing a TAVR procedure and which one is the most common?
A
transfemoral is the most common
19
Q
physiology of aortic regurgitation
A
- 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
-
LV failure can occur.
21
Q
- exam findings of aortic stenosis
- what is seen on ascultation?
- what about the rest of the physical exam?
A
- 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
-
high frequency diastolic mumur at right after S2 (or A2, closure of aortic valve)
- murmurs you might hear:
- 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)
-
LARGE PULSE PRESSURES (systolic - diastolic)
22
Q
exam findings seen with aortic regurgitation
A
