Aortic Stenosis

Question 1

Causes:

What is the main cause for all valve disease?

What is bicuspid aortic valve (BAV)?

What is rheumatic valve disease?

Answer 1

Calcification

Bicuspid aortic valve (BAV) is an inherited form of heart disease in which two of the leaflets of the aortic valve fuse during development in the womb resulting in a two-leaflet valve (bicuspid valve) instead of the normal three-leaflet valve (tricuspid).

Rheumatic heart disease is a condition in which the heart valves have been permanently damaged by rheumatic fever. The heart valve damage may start shortly after untreated or under-treated streptococcal infection such as strep throat or scarlet fever.

What is the difference between rheumatic fever and rheumatic heart disease?

RF is an inflammatory disorder caused by a Group A strep throat infection.
It affects the connective tissue of the body, causing temporary, painful arthritis and other symptoms.
In some cases rheumatic fever causes long-term damage to the heart and its valves. This is called rheumatic heart disease.

Question 2

S+S

Classic triad of symptoms - mnemonic SAD

Answer 2

Syncope
Angina
Dyspnoea on exertion

Question 3

Signs:

What type of murmur do you hear and where does it radiate to?

What type of pulse might you feel on the radial artery?

Is the pulse pressure wide or narrow?

What could you palpate on the chest during an examination?

Why is it high pitched?

Why is it called a crescendo-decrescendo?

You can always have a listen to the carotids for bruits to confirm!

Answer 3

Ejection systolic murmur
Carotids

Slow rising pulse due to delaying and slow flow through stiff valve

Reduced gap between systolic and diastolic due to reduced ejection volume - THE SYSTOLIC IS BASICALLY LOWER SO THEREFORE IT WILL BE NARROWED!

Aortic thrill

Due to the high velocity

Gets louder then quieter

Question 4

Ddx for systolic murmur:

When is the murmur from aortic stenosis the loudest?

When is the murmur from pulmonary stenosis the loudest?

Mitral regurg causes a pan-systolic murmur. What other valve can cause this? - think about the other side of the heart!

Answer 4

On expiration

On inspiration

Mitral regurgitation
Tricuspid regurgitation
VSD

Question 5

Investigations:

Echo - what it looks for?

What could an ECG show?

What could you see on CXR?

Answer 5

Degree of calcification
LV function
Aortic velocity
Pressure gradient

LVH
LBBB
AV block

LVH
Calcified valve
Dilate ascending aorta

Question 6

Investigations:

What other tests can be done?

• 2 IMAGING
• 1 BLOOD TEST

Answer 6

Cardiac MRI
Multi-slice CT

Bloods for BNP

Question 7

Management:

What imaging should be done every 6 months to look at progress?

A surgical aortic valve replacement (SAVR) can be done as definitive Rx.

TAVI:

• What does TAVI stand for?
• When is it used?
• What 2 routes can be used?
• Why is this not a valve replacement?

What post-op antiplatelets are used for both SAVR and TAVI?

Answer 7

Echo

Transcatheter aortic valve implantation
If patients unfit for SAVR

Transluminal - through the femoral or subclavian artery
Transapical - mini-thoracotomy

Old valve isn’t removed but simply pushed out of the way so not a valve replacement

Aspirin for life
Clopidogrel for 3-6 months

Question 8

Balloon valvuloplasty - what can it do?

Answer 8

Temporary relief for 6-12 months

A catheter (thin, flexible tube) is inserted into an artery in your groin, and a special dye is then used so that your aortic valve will show up on X-rays. A small balloon is then inflated in the aortic valve, which helps to increase blood flow through the heart. This procedure is done under a local anaesthetic and most patients will only need to come in the day of their procedure and stay overnight.

https://oneheartcardiology.com.au/service/balloon-valvuloplasty/

Question 9

Complications

Answer 9

LVF OR CHF
Aortic dilatation due to haemodynamic changes around valve
Infective endocarditis
Sudden cardiac death