Aortic Stenosis

Question 1

What are the causes of narrow pulse pressure?

Answer 1

Aortic Stenosis, Mitral Stenosis, Hypovolaemia

Question 2

What is the Gallavardian phenomenon?

Answer 2

When aortic stenosis murmur is loudest over the apex, rather than aortic area. This is usually observed in older pts where there is calcicfication of the ascending aorta

Question 3

What are the causes of aortic stenosis?

Answer 3

Congenital
Bicuspid valve
Degenerative
Rheumatic heart disease
RARER = paget's, endocarditis, hyperuraceamia

Question 4

What is an ejection systolic murmur?

Answer 4

Crescendo-Descendo murmur. Peak mid to late systole

Question 5

What is the DDx of an ES murmur, loudest in expiration?

Answer 5

Aortic Stenosis
William’s Syndrome (supervalvular aortic stenosis)
HOCM

Question 6

What is the normal aortic valve area?

Answer 6

3-4cm

Question 7

What aortic valve area is severe stenosis?

Answer 7

<1cm

Question 8

What gradient is severe stenosis?

Answer 8

MEAN gradient >50mmHg

Question 9

What are the clinic signs of severe aortic stenosis?

Answer 9

Narrow pulse pressure
Low pulse volume
Slow rising Pulse
Systolic Thrill
Heaving Apex
Diminished second heart sound
Reversed splitting (loud pulmonary component)
Pulmonary hypertension
Pulmonary congestion

Question 10

What are the causes of reversed splitting of the second heart sound?

Answer 10

Aortic Stenosis
LBBB
HOCM
Patent Ductus Arteriosus

Question 11

What are the complications of Aortic Stenosis

Answer 11

Left Ventricular Failure
Pulmonary Hypertension
Pulmonary Congestion
Arrhythmia (VTs, AF)
Heart Block
Sudden Death
Haemolytic Anaemia
Heye's Syndrome
Infective Endocarditis
Systemic Emboli

Question 12

Why do people with Aortic Stenosis get angina?

Answer 12

There is adapative change in the cardiac muscle (hypertrophy) but because hypertrophied hearts have decreased coronary artery blood flow, even in absence of coronary artery disease, this change is also maladaptive and predisposes to angina.

Question 13

What is the mechanism of syncope in aortic stenosis?

Answer 13

1. Low output cardiac state
2. Failure to increase cardiac output in response of peripheral vasodilatation - e.g caused by drugs or by exercise.
3. Transient electro-mechanical dissociation
4. Arrhytmia

Question 14

What might you see on the ECG of a patient with Aortic stenosis

Answer 14

Left Atria

• hypertrophies (bifed P wave in II)
• dilatation (terminal negative component to P in V1)
• LBBB
• LAD
• LVH
• LV Strain Pattern

Question 15

What three symptoms must you ask ALL patient’s with aortic stenosis?

Answer 15

Palpitations
Angina
Syncope

Question 16

What is Heyde’s syndrome?

Answer 16

Association of aortic stenosis with occult GI bleeding due to colonic angiodysplasia - perhaps due to destruction of VWBf from shearing force from aortic valve (ie aortic valve fixes it)

Question 17

What are the indications for aortic valve replacement in Aortic Stenosis?

Answer 17

1. Symptomatic pt with severe AS (gradient >50mmHg)
2. Asymptomatic pt with
   - LVSD and gradient >40mmHg
   - Valve area <0.6cm
   - VT
   - Abnormal BP response to exercise