aortic stenosis and regurg

Question 1

2 possible pathologies leading to A stenosis

Answer 1

1. bicuspid valve
2. degenerative
   - calcification or rheum

Question 2

what is the mech of problems with stenosis

Answer 2

1. outflow obstruction
2. pressure hypertrophy, diastolic dysfunction, ischemia
3. Sx
4. death

Question 3

what is pressure hypertrophy

Answer 3

LV pressure overload induces genes that promote concentric hypetrophy - big wall
- end up with muscle bound heart that can’t pump forward properly

Question 4

what are important points of progresson in A stenosis

Answer 4

• 50% reducdtion in orifice leads to minimal gradient
• beyond this there are exponential increases
• variable between people

Question 5

3 clinical manifestation

Answer 5

1. angina pectoris
2. syncope
3. dyspnea

Question 6

2 parts of angina pectoris

Answer 6

1. low supply
   - endocardial compression
   - assoc. CAD
2. high demand
   - LV hypertrophy
   - myocardial o2
   - wall stress

Question 7

what is syncope

Answer 7

• classically exertional

- may also be from an arrythmia

Question 8

what is dyspnea

Answer 8

1. LV hypertrophy
   - diastolic dysfunction
2. progressive LV dilatiation and contractile failure
   - systolic dysfunction
   signs and Sx of HF

Question 9

when is sudden death

Answer 9

0. 3% per year in asymptomatic PT

- malignant tachy or brady cardia

Question 10

what is nat. Hx

Answer 10

long asymptomatic latent period

- onset of Sx is a bad sign

Question 11

what is murmur like in stenosis worsening

Answer 11

as it get worse, it comes later and get harsher

Question 12

what is bicuspid valve

Answer 12

• prone to stenosis and regurg
• assoc. with AAA
• risk for aortic dissection, not coarctation
• risk for endocarditis

Question 13

5 parts of workup

Answer 13

1. ECG
   - LA enlargement, LV hyper
2. CXR
   - post stenosic Aortic dilatation
3. ECHO
   - thick and restricted leaflets
   - gradient and vavle area can be calculated
4. Cath
   - gradient across valve and valve area
5. stresst testing
   - for prognosis

Question 14

3 severity levels and measurments

Answer 14

mild - 40mmHg

Question 15

what is med. mgmt

Answer 15

mech problem = mech Tx

- afterload reducing drugs contraindicated

Question 16

4 reasons stenosis important

Answer 16

1. common
2. major clinical implications
3. morbid once Sx
4. treatable

Question 17

5 common errors in stenosis

Answer 17

1. failure to disting sclerosis from stenosis
2. failure to diagnoe/investigate
3. failure to act once Sx there
4. prescribing afterload reducing agents
5. abrupt reduction in preload/afterload

Question 18

3 possible causes of A regurg

Answer 18

1. diseased valve cusps
   - calc, bi cusp, rhuem
2. diseased aortic root
3. acute patho
   - dissection, trauma, endocarditits

Question 19

what is pathophys is acute

Answer 19

• acute Vol overload leads to high filling P
• LV doesn’t have time to accom.
• stroke vol goes up a bit, but not enough to deal with all the extra
• low forward output and high L atrium pressure

Question 20

what is patho in chronic

Answer 20

• get eccentric hypertrophy - cor bovinum
• v. large strok vol get blood forward well
• ejection fraction remains the same
• can stay compensated for a long time

Question 21

what happens in decomp.

Answer 21

• eventual LV fibrosis and systolic dysfunction
• wall tension and pressure rises over time
• evenutally ejection fraction falls

Question 22

what is natural Hx

Answer 22

• asymptomic for decades
• remodelling is asymptomaic for a while
• then get Sx and it is bad

Question 23

3 main Sx of regurg

Answer 23

1. palplitations - due to hyperdynamic stroke volume
2. failure
   - dyspnea on exertion, orthopnea, fatugue
3. angina, syncope

Question 24

what is heart sound with regurg

Answer 24

high pitched early diastolic murmur

Question 25

4 tests

Answer 25

1. ECG - LVH
2. CXR - megaly
3. ECHO
4. cath

Question 26

5 parts of med mgmt

Answer 26

1. surveillance ECHO
2. avoid bradycardia
3. vigilance against endocard
4. diuretics
5. vasodilators

Question 27

indications for surg

Answer 27

definite
- Sx with normal ejection fraction
- Sx with mild decrease EF
v. prob
- Asx but with sever LV dilatation
probable
- severe LV systolic dysfunction

Question 28

2 common errors

Answer 28

1. failure to monitor for asymptomatic but irreversible LV remodelling
2. over-reliance on meds on remodellig occurs

Question 29

what is surg

Answer 29

valve replacment