aortic valve (comprehensive) Flashcards
Q: What is the main topic of this lecture?
“Aortic Valve Disease”
Q: Who presented the lecture on Aortic Valve Disease?
“Dr. Jaber Al Majbery
Q: What are the anatomic components of the aortic root?
“The aortic sinuses (or sinuses of Valsalva)
Q: How are the morphology and function of the aortic valve best described?
“They are interrelated with the aortic root and best described as a single functional unit.”
Q: How does the diameter of the aortic annulus compare to the sinotubular junction?
“The diameter of the aortic annulus is 15% to 20% larger than that of the sinotubular junction.”
Q: How do the lengths of the free margins of the leaflets relate to the sinotubular junction?
“The free margins of the leaflets are slightly longer than the diameter of the sinotubular junction.”
Q: What is the morphology of calcific aortic stenosis?
“It is congenitally bicuspid
Q: What is the morphology of rheumatic aortic stenosis?
“It shows fibrous thickening of a 3-cusp valve
Q: What is the morphology of degenerative aortic stenosis?
“It involves diffuse nodular calcification of a 3-cusp valve with no commissural fusion.”
Q: What are the typical age-related causes of aortic stenosis?
“Under 70 years: congenital or rheumatic; Over 70 years: degenerative.”
Q: What is the transvalvular gradient in severe AS with normal cardiac output?
“It is greater than 50 mmHg.”
Q: What are the consequences of pressure overload in aortic stenosis?
“It leads to concentric left ventricular hypertrophy
Q: What are the symptoms of aortic stenosis?
“Initially asymptomatic
Q: What are the physical findings in aortic stenosis?
“Small volume
Q: What does a softer murmur indicate in aortic stenosis?
“It may indicate left ventricular failure.”
Q: What are the ECG findings in aortic stenosis?
“Left ventricular hypertrophy (LVH)
Q: What are the CXR findings in aortic stenosis?
“Left ventricular prominence with possible cardiomegaly (LV dysfunction)
Q: What imaging modalities are used to assess aortic stenosis?
“Echocardiogram with Doppler
Q: What is the prognosis of hemodynamically severe aortic stenosis?
“High risk of sudden death
Q: What is the prognosis of mild-to-moderate asymptomatic aortic stenosis?
“50% of patients remain event-free for 4 years.”
Q: What is the prognosis of mild-to-moderate symptomatic aortic stenosis?
“One-third of patients die within 4 years.”
Q: How does the onset of symptoms in aortic stenosis relate to mortality?
“The onset of symptoms correlates with a sharp increase in mortality risk.”
Q: Why does left ventricular hypertrophy occur in aortic stenosis?
“To maintain cardiac output through the narrowed valve orifice
Q: What causes exertional syncope in aortic stenosis?
“Peripheral vasodilation with fixed cardiac output leads to decreased cerebral perfusion; may also involve tachy- or bradyarrhythmias.”
Q: What is the role of vasodilators in symptomatic aortic stenosis?
“They are potentially dangerous but may be beneficial if used in ICU with close monitoring.”
Q: What medications can be used for symptomatic AS if CHF is present?
“Diuretics and digoxin.”
Q: Do medications treat the underlying pathology in AS?
“No
Q: What are key points for preventing infective endocarditis in valve disease?
“Maintain good oral hygiene and use aseptic measures during catheterization or invasive procedures to reduce the risk of healthcare-associated endocarditis.”
Q: What are the types of surgical valve replacement in AS?
“Mechanical valve
Q: What are the limitations of balloon valvuloplasty in AS?
“Poor initial success
Q: When can balloon valvuloplasty be considered in AS?
“As a bridge to surgery in hemodynamically unstable patients or in those requiring urgent non-cardiac surgery.”
Q: What is TAVI and when is it used?
“Transcatheter Aortic Valve Implantation is used in symptomatic severe AS
Q: How often should asymptomatic severe AS be re-evaluated?
“Every 6 months with monitoring of symptoms
Q: What is the follow-up schedule for mild and moderate AS?
“Yearly evaluation; in young patients without significant calcification
Q: What mechanisms can lead to aortic regurgitation (AR)?
“Cusp perforation
Q: What are the leaflet-related causes of AR?
“Cusp perforation
Q: What can cause cusp perforation?
“Infective endocarditis
Q: What structural issues lead to cusp prolapse in AR?
“Excess tissue
Q: What causes restrictive motion of aortic valve leaflets?
“Fibrous thickening of the cusps.”
Q: How does sinotubular junction dilatation lead to AR?
“It displaces the commissures outward
Q: What are the wall-related abnormalities causing AR?
“Annular dilatation
Q: What conditions can cause annular dilatation in AR?
“Marfan syndrome
Q: What is the combination that defines aortic root aneurysm?
“Sinotubular junction dilatation along with aneurysm of the sinuses of Valsalva.”
Q: What congenital conditions can lead to aortic regurgitation?
“Bicuspid valve
Q: What valve-related acquired conditions can cause AR?
“Cusp prolapse or shortening with rolled edges
Q: What aortic root pathologies can lead to AR?
“Dilation of the sinus of Valsalva
Q: What are the symptoms of chronic AR?
“Usually asymptomatic for a long period; later symptoms include exertional dyspnea
Q: What are the symptoms of acute AR?
“Sudden severe dyspnea
Q: What should be examined in patients with suspected AR?
“Look for signs of underlying diseases such as Marfan’s syndrome
Q: What are the key peripheral signs of chronic AR?
“Large volume pulse
Q: What are the cardiac examination findings in chronic AR?
“Forceful
Q: What are the murmur characteristics of AR?
“Early diastolic blowing high-pitched decrescendo murmur at the left 3rd and 4th intercostal spaces parasternally
Q: What does the duration of the diastolic murmur in AR correlate with?
“The severity of regurgitation.”
Q: What is the Austin Flint murmur?
“A mid-diastolic murmur caused by regurgitant blood interfering with the opening of the anterior leaflet of the mitral valve during diastole.”
Q: What are the clinical signs indicating severe AR?
“Wide pulse pressure
Q: What is the natural history of chronic AR?
“Long latent period before cardiac decompensation; sudden death is rare; once LV deterioration starts
Q: When should surgery be considered in symptomatic AR?
“Prompt operation is indicated in patients with congestive heart failure
Q: What is the recommended management for asymptomatic AR?
“Monitor for left ventricular enlargement or dysfunction using echocardiography; operate at the appropriate time.”
Q: What is the acute management of severe AR?
“Immediate surgery is the treatment of choice.”
Q: How should a patient in cardiogenic shock from acute AR be managed?
“Administer IV vasodilators; if AR is severe
Q: What is the medical treatment for chronic AR?
“Use calcium channel blockers
Q: What is the definitive treatment for symptomatic chronic AR?
“Aortic valve replacement (AVR).”
Q: What is the role of infective endocarditis prophylaxis in AR?
“Essential in all patients with valvular heart disease to reduce healthcare-associated infections; includes good oral hygiene and aseptic technique.”
Q: What is the follow-up schedule for mild-to-moderate AR?
“Yearly clinical review and echocardiography every 2 years.”
Q: What is the follow-up plan for severe AR with normal LV function?
“Follow-up at 6 months after initial assessment.”
Q: What are the indications for surgery in symptomatic aortic regurgitation?
“Presence of dyspnea (NYHA class II
Q: When is surgery indicated in asymptomatic AR with preserved LV function?
“If there is severe LV dilatation: end-diastolic dimension >70 mm or end-systolic dimension >50 mm (or >25 mm/m² BSA).”
Q: What are surgical indications in patients undergoing other cardiac procedures?
“Patients having CABG or surgery on the ascending aorta or another valve should also have AVR if indicated.”
Q: What are the threshold aortic diameters for surgery in aortic root disease?
“More than 45 mm in Marfan syndrome
Q: What additional anatomical considerations guide surgery for aortic root?
“Shape and thickness of ascending aorta and other parts of the aorta should be considered.”
Q: What is the basic anatomical layout of the aortic root and valve area?
“It includes the aortic wall
Q: What are the three levels where aortic stenosis can occur?
“Supravalvular
Q: What syndrome is associated with supravalvular aortic stenosis?
“Williams syndrome.”
Q: What are features of Williams syndrome?
“Elfin-like facies
Q: What are examples of subvalvular causes of aortic stenosis?
“Discrete fibromuscular ring (10% of congenital AS)
Q: What are subvalvular anomalies linked with AV canal defects?
“Parachute mitral valve deformity with fused papillary muscles.”
Q: What is an anacrotic pulse and what does it indicate?
“A low volume
Q: What is pulsus alternans and when is it seen?
“Alternating strong and weak pulse; seen in severe left ventricular dysfunction.”
Q: What is a classic auscultatory finding of aortic stenosis murmur?
“Ejection systolic murmur heard at the base
Q: What is the significance of a soft or inaudible A2 in AS?
“It may indicate a calcified and immobile valve.”
Q: What is the Austin Flint murmur and in which condition does it occur?
“A mid-diastolic murmur due to regurgitant aortic blood interfering with mitral valve opening; occurs in severe AR.”
Q: What is the typical progression of valvular aortic stenosis in adults according to postmortem data?
“There is a latent period followed by symptom onset
Q: What defines severe aortic stenosis?
“Aortic valve area <1 cm² or <0.6 cm²/m² body surface area.”
Q: What is the significance of an ejection fraction <50% in AS?
“It indicates reduced left ventricular function and influences management decisions.”
Q: What is the clinical approach for physically active patients with AS?
“Perform an exercise test; if abnormal
Q: What does a marked increase in peak jet velocity over 1 year suggest in AS?
“It may indicate rapid progression and worsening of stenosis.”
Q: What pulse characteristics are associated with AR?
“Collapsing (water hammer) pulse
Q: What causes a hyperdynamic apex in AR?
“Large stroke volume due to volume overload of the left ventricle.”
Q: What is Hill’s sign in AR?
“A difference in systolic pressure >60 mmHg between popliteal and brachial arteries.”
Q: What is the typical murmur of AR?
“A full-length
Q: What happens to S2 in severe AR?
“A2 may be inaudible and P2 may be obscured.”
Q: When does the Austin Flint murmur disappear?
“In severe AR with premature mitral valve closure.”
Q: What are surgical indications in AR with left ventricular dilation?
“End-diastolic dimension >70 mm or end-systolic dimension >50 mm or >25 mm/m² BSA.”
Q: What factors determine surgical threshold in patients with aortic root disease?
“Maximal aortic diameter (>45 mm in Marfan’s
Q: When can surgery on the ascending aorta be combined with AVR?
“If surgery on the aortic valve is already indicated
Q: What change during follow-up might prompt surgery for AR?
“Significant changes in symptoms
Q: What is the purpose of classifying levels of aortic stenosis?
“To identify whether the stenosis is supravalvular
Q: What anatomical structure lies between the aortic valve and the sinotubular junction?
“The interleaflet triangle.”
Q: What is the ‘ventriculo-arterial junction’?
“The junction between the left ventricle and the aorta
Q: What does the basal ring represent anatomically?
“It is a fibrous ring at the base of the aortic valve within the left ventricle.”
Q: What is the relationship between the sinotubular junction and the ascending aorta?
“The sinotubular junction marks the transition from the aortic root to the ascending aorta.”
Q: In which direction is the apex beat displaced in AR?
“Downward and laterally
Q: What effect does large stroke volume have on the pulse?
“It creates a bounding
Q: What murmur timing and location are characteristic for AR?
“An early diastolic murmur at the left 3rd–4th intercostal space
Q: What is the significance of murmur duration in AR?
“The longer the murmur
Q: What happens to S1 and S2 in aortic stenosis with calcification?
“S1 is soft; A2 (part of S2) may become inaudible if the valve is heavily calcified.”
Q: Why might the second heart sound (S2) be reversed in AS?
“Due to prolonged left ventricular ejection time.”
Q: What is a ‘boot-shaped’ heart on CXR typically associated with?
“Left ventricular hypertrophy or dysfunction as seen in severe aortic valve disease.”
Q: What does a paradoxically split S2 indicate?
“It may indicate delayed aortic valve closure
Q: What is the role of echocardiography in aortic valve disease?
“It is essential for evaluating valve anatomy
Q: What type of follow-up is required after AVR or in severe valve disease?
“Regular clinical and echocardiographic follow-up to monitor symptoms
