Aortic Stenosis

Question 1

Compare presentation, dynamicity and treatment options for stenosis vs. regurgitation

Answer 1

Stenosis = chronic, not dynamic and requires mechanical treatment (surgery)

Regurgitation = acute OR chronic presentations are distinct, HIGHLY dynamic (affected by pressure and loading) and can be treated with medical or mechanically

Question 2

Acute regurgitation

Answer 2

Acute rise in pressure in chamber into which regurgitant jet is redirected

Question 3

Chronic regurgitation

Answer 3

Chamber enlargement into which regurgitant jet is directed

Question 4

What is the typical aortic valve area?

Answer 4

3-4cm^2

Question 5

Top causes of aortic stenosis

Answer 5

1. Degenerative calcification
2. Calficication of bicuspid valve
3. Rheumatic heart disease
4. Supravalvular e.g. William’s syndrome
5. Subvalvular e.g. HOCM

Question 6

Aortic stenosis pathophysiology

Answer 6

Chronic LV pressure overload
Concentric LV hypertrophy
Non-compliant ventricle --> raised LVEDV
Left atrial enlargement
Increased risk of arrhythmias
Pulmonary oedema
Eventual congestive cardiac failure

Question 7

Signs of severe AS

Answer 7

Absent A2
Present S4
Narrow pulse pressure
Signs of LVH

Question 8

Difference between AS and aortic sclerosis?

Answer 8

Aortic stenosis: valve narrowing, narrow PP, forceful apex beat (non-displaced), ESM radiating to carotids

Aortic sclerosis: valve thickening, asymptomatic, ESM with NO RADIATION TO CAROTIDS

Question 9

Diagnostic test for AS?

Answer 9

Echo + Doppler:
Thickened, calcified and immobile valve cusps
Severe AS AHA criteria: <1cm^2 ARA, > 40 mmHg TVG,
jet velocity >4m/s^2

Question 10

Surgical options for AS?

Answer 10

1. Replacement (mechanical or bioprosthetic)
2. Balloon valvuloplasty
3. Transcatheter aortic valve implantation (TAVI)

Question 11

How to decide what type of valve replacement for AS?

Answer 11

Younger patients typically given mechanical valves since they last longer but require lifelong anticoagulation. *Young females on lifelong anticoag should not be given warfarin due to risk of fetal intracranial haemorrhage.

Older patients given prosthetic valves; no anticoag needed but only lasts around 10-15 years.

Question 12

What is Ross’s procedure for AS?

Answer 12

Autograft of pulmonary valve to aortic position, re-implantation of coronary arteries and homograft at pulmonic position.