Aortic valve disease Flashcards
Aetiology of aortic stenosis
- Senile calcification (most common - 80%)
- Congenital (bicuspid valve, William’s syndrome)
- Rheumatic heart disease (uncommon in industrialised countries)
Risk factors for aortic stenosis
Age >60yrs
Bicuspid aortic valve
Rheumatic heart disease
CKD
Smoking
Hypertension
Diabetes
Radiotherapy
High LDL cholesterol
Hyperlipoproteinemia
Symptoms of aortic stenosis
Long subclinical period (asymptomatic)
Chest pain (angina)
Exertional dyspnoea (heart failure)
Syncope
Dizziness
Reduced exercise tolerance (SOB)
Epistaxis or bruising
Signs of aortic stenosis on examination
Slow rising pulse with narrow pulse pressure (<30mmHg)
Diminished and delayed carotid upstroke (parvus et tardus)
Heaving, non-displaced apex beat
Palpable thrill
Ejection systolic murmur (crescendo and decrescendo)
- Right 2nd ICS
- Louder on expiration
- Radiate to the carotid arteries
- Loudest at the right upper sternal border and terminates with S2
Severe stenosis -> splitting of second heart sound in expiration (pulmonary sound comes slightly before)
- May hear S4 (blood fills a non-compliant ventricle)
- Absent S2 + S4
Investigations for aortic stenosis
ECG: LVH with strain pattern | P-mitrale | LAD | LBBB | complete AV block
FBC
Troponin
BNP
Lipid profile
Glucose
CXR: LCH, calcified aortic valve, post-stenotic dilation of the ascending aorta
Echo: diagnostic - aortic valve narrowing, valve area <1cm^2, pressure gradient >40, jet velocity >4
Cardiac catheter + coronary angiography: assess function
Management for aortic stenosis
General:
- MDT (cardiologist, GP, specialist nurses, cardiothoracic surgeon, dietician, OT/physiotherapist)
- RF modification (QRISK → statin, anti-platelet; managenHTN, angina, etc.)
- Regular follow up
→ Mild: echo every 3-5 years
→ Moderate: echo every 1 to 2 years
Surgery:
- Open valve replacement
- TAVI (transcatheter AV implantation)
- Balloon valvuloplasty
- Sutureless AV replacement
What are the surgical options for aortic stenosis
[1] open replacement (ix: symptomatic, non-symptomatic w/ low EF (<50%), severe undergoing CABG)
- Artificial:
- Starr-Edwards / ball-in-cage [3 artificial sounds]
- Tilting disc / bileaflet [1 artificial sound]
- Biological
[2] TAVI (Transcatheter AV Implantation)
+ve = no bypass required, no large scars
-ve = higher risk of stroke (as compared to open replacement)
[3] balloon valvuloplasty
[4] sutureless AV replacement (less time on bypass)
How do you tell the difference between artificial valves
Starr-Edwards / ball-in-cage [3 artificial sounds]
- Quiet click as valve opens
- Rumbling as ball rolls in the cage
- Loud thud as valve closes
Tilting disc / bileaflet [1 artificial sound]
- High-pitched click as valve closes
Biological:
Biological valve [normal heart sounds]
Prognosis for aortic stenosis
For patients with mild or moderate stenosis, the aortic valve area decreases on average by 0.1 cm²/year and the mean gradient increases by 7 mmHg annually
Symptomatic: average survival of only 2 to 3 years without surgery
Between 8% and 34% of symptomatic patients die suddenly
Surgical replacement of the aortic valve is extremely effective therapy.
Aetiology for aortic regurgitation
By primary disease of the aortic valve leaflets or dilation of the aortic root
Congenital bicuspid aortic valve and aortic root dilation account for most cases in developed countries
Root dilation: Marfan’s, aortitis secondary to syphillis, Behcet’s, Takayasu’s, reactive arthritis, ankylosing spondylitis
Rheumatic heart disease is the most common cause in developing countries
May also be due to endocarditis (→ rupture of leaflets or paravalvular leaks) or vegetations on the valvular cusps, or aortic root dissection
May develop acutely or over many years in progressively increasing severity
Symptoms of aortic regurgitation
Chronic AR is initially asymptomatic → symptoms of HF
Dyspnoea
Fatigue
Weakness
SOB
- Orthopnoea (lying down)
- Paroxysmal nocturnal dyspnoea (needs more pillows to sleep)
Pallor
Chest pain, wheeze, syncope
Severe acute AR → sudden cardiovascular collapse
Signs of aortic regurgitation on examination
Early diastolic murmur
- Left sternal edge, Erb’s point (L 3rd ICS)
- Patient sitting forward in expiration
Collapsing/water-hammer pulse, rapid
Wide pulse pressure
Heaving displaced apex beat
Soft S2 ± S3 (blood fills against compliant ventricle)
Pallor
Mottled extremities
HF: Raised JVP, basal lung crepitations, pink frothy sputum
Cyanosis
Tachypnoea
Austin Flint murmur: soft, rumbling, mid-late diastolic murmur at the apex. Distinguished from mitral stenosis by the ABSENCE of an opening snap and loud S1
Hill’s sign: SBP over popliteal artery > brachial SBP by >600mmHg
Bisferiens pulse: Double systolic arterial impulse
de Musset’s sign: Patient’s head may bob with each heart beat
Muller’s sign: pulsations of the uvula
Traube’s sign: Pistol shot sounds over the femoral artery with each compression
Quincke’s sign: Subungual or lip capillary pulsations
Duroziez’s sign: Systolic and diastolic murmurs heard over the femoral artery when compressed proximally and distally respectively
Mayen’s sign: DBP drop >15mmHg with arm raised
Lighthouse sign: Blanching and flushing of the forehead
Becker’s sign: Pulsation of retinal vessels
Landolfi’s sign: Alternating constriction and dilation of pupil
Rosenbach’s sign: Systolic pulsations of the liver
Lincoln’s sign: Pulsatile popliteal artery
Sherman’ sign: Dorsalis pedis pulse is unexpectedly prominent >75
Investigations for aortic regurgitation
ECG: LVH with strain pattern| LAD | LBBB | complete AV block
FBC
Troponin
BNP
Lipid profile
Glucose
ESR
HLA-B27
ANA
CXR: Cardiomegaly, Dilation of the ascending aorta, Signs of pulmonary oedema
Echo: diagnostic - confirms reflux of blood assess severity (jet width >65% outflow tract, regurgitant jet volume, premature closing of mitral valve)
Cardiac catheter + coronary angiography: assess function
Management for aortic regurgitation
General:
- MDT (cardiologist, GP, specialist nurses, cardiothoracic surgeon, dietician, OT/physiotherapist)
- RF modification (QRISK → statin, anti-platelet; managenHTN, angina, etc.)
- Regular follow up
Medical
Reduce afterload → ACEi, BB, diuretics
Surgical (valve replacement before LV dilatation and dysfunction); ix= NYHA >2 OR LV dysfunction:
- Pulse pressure >100mmHg
- changes (TWI in lateral leads)
- LV enlargement on CXR or EF <50%
Prognosis for aortic regurgitation
Depends on the magnitude of left ventricular (LV) function and symptoms
The 5-year survival in patients with normal LV function has been reported as 96% whereas that in patients with reduced LV function is 62%
