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Cardiac 2 > Aortic Stenosis > Flashcards

Aortic Stenosis Flashcards

1
Q

Where are S1 heart sounds best heard?

A

Lower left sternum and apical region

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2
Q

Where are S2 heart sounds best heard?

A

2nd and 3rd intercostal space

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3
Q

What heart sound is also known as S3?

A

Ventricular Gallop

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4
Q

In what population are S3 heart sounds normal?

A

Normal in children and young adults and abnormal in middle-aged and older adults

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5
Q

What is S4 heart sound also called?

A

Atrial Gallop

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6
Q

When does Atrial Gallop occur in terms of the other heart sounds?

A

After S2 but before S3

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7
Q

What part of the cardiac cycle does atrial gallop occur and what does it coincide with?

A

Late diastole - coincides with atrial contraction

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8
Q

What is the “opening snap” sound associated with?

The opening snap occurs between what two heart sounds?

A

High pitched sound associated with mitral or tricuspid stenosis.

Occurs between S2 and S3

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9
Q

What are ejection click sounds?

A

Abnormal early systolic sounds

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10
Q

When do ejection clicks occur?

A

After S1

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11
Q

What sounds signify MV vs. AoV stenosis?

A

MV = opening click sound (after S2, before S3)

AoV = ejection click sounds (after S1)

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12
Q

Is MV or TV prolapse more common?

A

MV

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13
Q

What type of flow cause heart murmurs?

A

Turbulent

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14
Q

Causes of Ao stenosis

A
  1. Bicuspid valve
  2. Inflammatory (rheumatic)
  3. Calcific - age related changes
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15
Q

Clinical symptoms of stenosis usually occur when the orifice is how much it’s original size?

A

1/4

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16
Q

What will happen to the ventricle over time with AoV stenosis?

A

Ventricle is working harder to push blood and will become thicker and hypertrophic - pressure overload - concentric LVH where there are smaller chambers and thicker walls

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17
Q

What happens to the LV and LA with Ao stenosis?

A
  1. LV becomes stiff and hypertrophic
  2. LA dilates to fill stiffened ventricle
  3. Significant pressure overload
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18
Q

What happens to coronary artery perfusion with Ao stenosis?

A

Decreased perfusion time due to a decreased diastolic filling period

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19
Q

What is vena contracta

A

The narrowest regional cross-sectional area - where blood flow is the most constricted

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20
Q

What type of stenosis are commissures seen?

A

Rheumatic only

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21
Q

What is the first stage of thickening called in age-related AoV stenosis?

A

Aortic sclerosis

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22
Q

What is the most common indication for valve replacement surgery?

A

Aortic sclerosis

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23
Q

What abnormality is known as focal areas of increased echogenicity at the base of the leaflets without significant LV outflow obstruction

A

Aortic sclerosis

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24
Q

When does age-related calcific Ao stenosis manifest?

A

70-85 years

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25
Q

What accounts for 2/3rds of severe Ao stenosis cases in adults and younger than 70 years?

A

Bicuspid valve

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26
Q

What has a “domelike” appearance of the Ao valve in PLAX view?

A

Bicuspid valve

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27
Q

What is the most common bicuspid valve variation? (hint: which cusps are fused?)

A

RCC and LCC

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28
Q

In what phase of the cardiac cycle is a bicuspid AoV assessed?

A

Systole

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29
Q

What structure appears tri-leaflet in diastole in a bicuspid AoV?

A

Raphe

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30
Q

When does Ao rupture and dissection risk increase with a bicuspid AoV?

A

When the ascending Ao measure < 45mm

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31
Q

What is the MOST COMMON complication of a bicuspid AoV?

A

Valve stenosis

32
Q

After identifying an enlarged Asc Ao and bicuspid valve, when should the next exam be?

A

6 months later

33
Q

What is a significant cause of aortic stenosis worldwide but is uncommon in developed countries?

A

Rheumatic Ao stenosis

34
Q

T or F? Aortic rheumatic valve disease is always isolated?

A

False: It is NEVER isolated and always associated with MV rheumatic disease

35
Q

What are the SF associated with rheumatic Ao stenosis?

A
  1. Increased echogenicity of leaflets
  2. Commissural fusion (only with rheumatic disease)
  3. Systolic doming of Ao leaflets
36
Q

What is involved in fixed subvalvular obstruction and when in the cardiac cycle does peak veloicty occur?

A
  1. Subaortic membrane
  2. Muscular subaortic stenosis

Peak velocity occurs at beginning of systole

37
Q

What is an example of a dynamic subaortic obstruction and when in the cardiac cycle does it occur?

A

Hypertrophic cardiomyopathy - mid to late systole

38
Q

Where in the cardiac cycle does supravalvular aortic stenosis occur?

A

Mid-systole

39
Q

What is the STRONGEST predictor of the clinical outcome when it comes to Ao stenosis? (hint: measurement)

A

Peak Ao jet velocity

40
Q

In determining max Ao jet velocity, what views should we be in to assess and do we use CW or PW?

A

Use CW in both AP5 and AP3

41
Q

How do we obtain the higher doppler recordings when measuring peak Ao jet velocity?

A

Using the pedoff probe - detects higher doppler readings

42
Q

Is the signal to noise ratio higher or lower in using the sector probe vs. pedoff probe?

A

Signal:noise ratio is HIGHER in pedoff probe

43
Q

What will happen when the doppler beam is not completely parallel to flow? (will the peak measurement be under or overestimated) ?

A

UNDERestimated

44
Q

What information should be taken into consideration in determining Ao stenosis vs other pathologies?

A
  1. Timing in cardiac cycle
  2. Shape
  3. Diastolic flow curves
45
Q

The continuity equation is based on what?

A

Conservation of mass

46
Q

What is the location of the EOA?

A

At the NARROWEST portion of the jet flow

47
Q

What is the stroke volume of the LVOT?

A

CSA (cross-sectional area) (A1) x VTI (V1)

48
Q

T or F? Outflow tract diameter remains relatively constant over time?

49
Q

Where is LVOT VTI best evaluated? (hint: what window)?

A

AP5 is the recommended

50
Q

In what windows do you measure AV peak velocity (V2) to determine the highest velocity?

A

AP5
AP3
SSN
RPS

51
Q

What is an important precursor of Aortic Stenosis?

A

Aortic Sclerosis

52
Q

What is the most common cause of Aortic Stenosis in individuals under 50 yrs?

A

Congenital malformations - bicuspid valve

53
Q

When do we use the indexed aortic valve area?

A
  1. On either very small or large patients
  2. When AS velocity is >4m/s (severe), but AVA is >1.0 (not severe)
54
Q

What is the equation for indexed aortic valve area?

A

AVA/BSA (body surface area)

55
Q

In middle-age and older adults, what is S3 heart sound a sign of?

A

Volume overload or increased flow across the valve

  1. CHF
  2. Regurgitation
56
Q

When does S4 sound occur?

A

Late Diastole as it coincides with atrial contraction

57
Q

What heart sound indicates diastolic dysfunction?

A

S4 or Atrial Gallop

58
Q

T or F? Ejection clicks and opening snaps are normal sounds?

A

FALSE: Opening snaps are a sign of MV and TV stenosis and ejection clicks are a sign of AoV or PV stenosis or dilation of the pulmonary artery or aorta

59
Q

What abnormalities are associated with “ejection clicks” heart sound?

A
  1. Ao stenosis
  2. Pulmonic V stenosis
  3. Aortic dilation
  4. PV dilation
60
Q

Why do mid to late extra systolic heart sounds occur?

A

Due to systolic prolapse of the MV or TV

61
Q

What is seen on echo with MV or TV prolapse? (2)

A
  1. Regurgitation
  2. Bulging of valves back into atria
62
Q

Name the systolic murmurs and what they are associated with.

A
  1. SEM (systolic ejection murmur) associated with AoV and PV stenosis, Ao dilation and pulmonary artery dilation
  2. Pansystolic/holosystolic murmur associated with MV and TV regurgitation and VSD’s
  3. Late systolic murmur associated with MV prolapse
63
Q

Name the diastolic murmurs and what they are associated with.

A
  1. Early diastolic associated with Ao and PV regurgitation
  2. Mid-diastolic associated with MV and TV stenosis
64
Q
  1. What are continuous murmurs associated with and what part of the cardiac cycle is it seen in?
A

Patent ductus arteriosis in both diastole and systole

65
Q

When assessing for a bicuspid valve in M-mode tracing, where is the cursor placed?

A

ON the leaflet tips

66
Q

What is the best view to diagnose a bicuspid valve?

67
Q

Accurate identification of a bicuspid valve is seen in PSAX during what part of the cardiac cycle?

68
Q

Most important complications with bicuspid valve? (slide 48)

A
  1. Dissection and rupture (if Asc Ao measures <45mm)
  2. Stenosis (most common)
  3. Regurgitation
  4. Infective endocarditis
69
Q

What is rheumatic disease ALWAYS associated with?

A

Rheumatic MV disease

70
Q

Where is the LVOT VTI obtained from? (what window)

71
Q

What are the velocities of the Aortic valve jets and their severity?

A

Aortic sclerosis: < or = 2.5 m/s

Mild: 2.6-2.9

Mod: 3-4

Severe: >4

72
Q

What are the AVA’s and their corresponding severities?

A

Mild: > 1.5

Mod: 1-1.5

Severe: < 1

73
Q

Why does an increased HR decrease filling time?

A

There is less time for the ventricle to fill with blood between contractions which reduces stroke volume

74
Q

When would you use indexed aortic valve area? What is this formula?

A

When there is low flow low gradient aortic stenosis and EF is normal, could be due to body size.

Formula: AVA/BSA

75
Q

What changes occur in the LV due to Aortic Stenosis?

A
  1. Increased thickness (concentric hypertrophy) without chamber dilation
  2. Diastolic function declines EARLY in the disease
  3. Systolic function declines LATER in the disease
  4. Impaired relaxation due to stiffer ventricle
  5. Has pseudonormal or restrictive filling patterns
  6. Compromised flow to the coronaries
76
Q

What are the mean pressure gradients along with their severity across the Ao valve in Ao stenosis?

A

Mild: <20 mmHg

Mod: 20-40 mmHg

Severe: >40 mmHg

Cardiac 2 (6 decks)

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