Aortic Stenosis

Question 1

Triad of AS

Answer 1

Chest pain (5 yr mean survival)
Breathlessness (2yr)
Syncope (18 month)

Question 2

Signs of complications of AS

Answer 2

Endocarditis
Heart failure
Conduction problems
Emboli events

Question 3

Clinical signs of AS

Answer 3

Narrow PP
Slow rising pulse
ESM heard louder on expiration radiating to carotids
Heaving pressure loaded apex
reverse split of S2
S4

Question 4

What is Gallivardins phenomenon?

Answer 4

high frequency of AS murmur heard louder over mitral area at apex (confused with MR)

Question 5

How can AS severity be judged

Answer 5

Presence of S4
Soft S2
Slow to get to ESM
Symptomatic

Question 6

Aetiology of AS

Answer 6

Common: calcifications of valve with age, bicuspid AV (tends to be younger)
Others: IE, Pagets, Fabrys, SLE, subvalvular obstruction (HOCM), supravalvular obstruction (Williams syndrome), rheumatic fever

Question 7

DDX of AS. How to differentiate

Answer 7

Pulmonary stenosis : Normal pulse, heard on inspiration, radiation to left infraclavicular space, younger
Aortic sclerosis (in practice mild AS): no radiation to carotids
VSD: may have ESM/PSM qualities. associated with congenital conditions, louder at sternal edge, may have thrill at sternal edge
HOCM: jerky pulse, quiet on squatting, loud on standing, no ejection click, normal S2

Question 8

ECG of AS

Answer 8

LVH

Question 9

Investigations of AS

Answer 9

ECG
TTE
Stress echocardiogram
Cardiac catheterisation

Question 10

Why would you do cardiac catheterisation in AS?

Answer 10

Assess coronary arteries and plan to do CABG as same time as AVR if surgery is planned

Question 11

What features on TTE are you looking for in AS

Answer 11

Valve area
Mild >1.5cm2, Mod 1-1.5cm2, Sev <1cm2

Mean valve gradient
Mild <20mmHh, Mod 20-40, Sever >40mmHg

Question 12

Why is stress echocardiogram useful

Answer 12

in the presence of poor LV function to decide whether the impaired LV is due to severe AS and therefore may benefit from surgery, or if the main problem is due to intrinsic myocardial disease with incidental and non-contributory AS, which does not improve with aortic valve replacement

Question 13

How often should AS be followed up?

Answer 13

If asymptomatic, it is generally recommended that 6–12-monthly follow

Question 14

Who should be considered for surgical intervention?

Answer 14

Symptomatic severe AS
>40mmHg and any of follow (EF<45%, abnormal hypotension to exercise, VT, valve area <0.6cm2)

Question 15

What the the options for valve replacement

Answer 15

Tissue AV
Mechanical AV
TAVI (unfit for open surgery)

Question 16

Associated conditions in AS

Answer 16

Coarctation of the aorta (remember to check for radio-femoral delay).
Other valvular disease, particularly mitral in rheumatic valvular disease.
Angiodysplasia of the colon and anaemia.

Question 17

Medical Rx of AS

Answer 17

Beta blocks

Question 18

Drugs to avoid in AS

Answer 18

Anything that reduces afterload (nitrates/ ACEI)