Aortic Stenosis-Insufficiency Flashcards
What are the 4 AORTIC ROOT anatomic components:
- The aortic annulus or aortoventricular junction
- The leaflets
- The aortic sinuses or sinuses of Valsalva
- The sinotubular junction
The morphologic characteristics and function of the aortic valve are interrelated to the aortic root and are best described as a single functional unit. The diameter of the aortic annulus is
15% to 20% larger than the diameter of the sinotubular junction.
Severe AS & normal cardiao output =
transvalvar gradient >50mmHg
normal aortic valve area =
3.0 to 4.0 cm2
MILD Aortic Stenosis
Mean Gradient :
Aortic Valve Area:
Mean Gradient : < 25
Aortic Valve Area: > 1.5
Moderate Aortic Stenosis
Mean Gradient :
Aortic Valve Area:
Mean Gradient : 25 - 40
Aortic Valve Area: 1.0 - 1.5
Severe Aortic Stenosis
Mean Gradient :
Aortic Valve Area:
Mean Gradient : > 40
Aortic Valve Area: < 1.0
Critical Aortic Stenosis
Mean Gradient :
Aortic Valve Area:
Mean Gradient : > 70
Aortic Valve Area: < 0.6
AS: Clinical Picture Symptoms
- Asymptomatic
- Syncope
- Angina
- CHF
- Sudden Death
HAEMODYNAMICALLY SEVERE
symptomatic or asymptomatic
- Sudden death risk high
- Immediate operation is indicated
HAEMODYNAMICALLY MILD – MODERATE (asymptomatic)
- 50% event free for 4 years
- Operation is not urgent, but patients should be followed carefully as the disease advances rapidly
HAEMODYNAMICALLY MILD – MODERATE (SYMPTOMATIC)
- One-third will die within 4 years
- Prompt operation is indicated
Natural History Progression average for Aortic Stenosis ?
0.1 cm2 per year
Management of Aortic Stenosis for an Asymptomatic patient (Mild - Moderate) ?
- Medical follow up
- Regular ECHO
- Avoid strenuous exercise
- Endocarditis prophylaxis
- ? Role for statins
- Progress ~0.1cm2 per year
Management of Aortic Stenosis for an Symptomatic patient with the following symptoms?
- Angina, syncope, failure
- Moderate AS + CAD
- Reduced BP on exercise
- Severe AS & reduced LV function
AVR
Infective endocarditis, Trauma, or
Iatrogenic cause leads to _________, which causes Aortic Regurgitation due to abnormalities of the leaflets.
Cusp Perforation
Excess of tissue, Disrupted commissure, and Commissural malposition leads to _________ which causes Aortic Regurgitation due to abnormalities of the leaflets.
Cusp prolapse
Fibrous thickening can lead to ________ which causes Aortic Regurgitation due to abnormalities of the leaflets.
Restrictive motion
4 Congenital Defects that lead to Aortic Regurgitation
- Bicuspid valve
- Supra-valvar stenosis
- Supra-cristal VSD and right coronary prolapse
- Sinus of Valsalva aneurysm
5 valve acquired diseases which lead to Cusp prolapse or cicatricial shortening of cusps with rolled edges which eventually lead to Aortic Regurgitaion ?
- Rheumatic fever
- Infective endocarditis
- Rheumatoid disease
- SLE
- Hurler’s syndrome
6 Aortic Root acquired diseases which lead to Dilation of sinus aorta and failure of coaptation of cusps which eventually lead to Aortic Regurgitaion ?
- Dissection
- Syphilis
- Cystic medial necrosis e.g Marfans – annulo-aortic ectasia
- Arthritides with aortitis e.g. Ankylosing spondylitis
- Hypertension
- Trauma
Medical MANAGEMENT of AR ?
- Calcium channel blocker
- Regular ECHO
- Avoid isometric exercise
- Endocarditis prophylaxis
- Monitor for symptoms
- Protracted course
Management of AR if patient is symptomatic ?
AVR
AR patient is asymptomatic if ?
- LVESD > 50-55mm
- LVEDD > 70-75mm
- LVEF < 55%
AVR very effective treatment even in patients over age
70 or 80
Even the best patients over age 80 have
reduced reserve
9 Increased risks during AVR if
- Emergency
- NYHA Class III – IV
- > 65 years old
- Severe AS AVA70, LVEDP>20
- Impaired LV systolic function
- Need for other procedure (CABG)
- Renal dysfunction
- Small BSA
- Redo operation
Post op complications for AVR ?
- Operative mortality: ~ 5%
- Complete heart block
- Ischemic heart disease (6 months from coronary ostial
stenosis) - CVA 3 – 5%
What is the percentage of 5 year survival prognosis for patients with normal LV function who underwent an AVR ?
96%
