Aortic Valve Disease

Question 1

What is the most common valvular disorder in developed countries?

Answer 1

Aortic stenosis

Question 2

Give 3 causes of aortic stenosis

Answer 2

1) age related calcification

2) bicuspid aortic valve

3) rheumatic heart disease

Question 3

What is the most common cause of AS in developed countries?

Answer 3

age-related degenerative calcification (typically >65 y/o)

Question 4

How can having a bicuspid aortic valve lead to aortic stenosis?

Answer 4

Predisposes to early calcification and stenosis.

Typically associated with earlier and more aggressive AS.

Question 5

How does the initial damage caused by rheumatic fever usually affect the aortic valve?

Answer 5

usually leads to a mixed aortic valve disease (stenosis and regurgitation).

Question 6

How does AS affect the LV?

Answer 6

The increased pressure gradient across the aortic valve leads to pressure overload on the LV, causing LVH.

This can lead to diastolic dysfunction and eventually heart failure.

Question 7

How can AS result in myocardial ischaemia?

Answer 7

The hypertrophied LV requires more O2, and the decreased aortic valve area can lead to decreased coronary perfusion.

Question 8

Clinical features of AS?

Answer 8

1) Exertional dyspnoea

2) Exertional angina

3) Exertional syncope or presyncope

4) HF symptoms

5) AF

Note - patients with AS may be asymptomatic for a prolonged period of 10-20 years.

Question 9

What is the most common initial complaint of AS?

Answer 9

Exertional dyspnoea

Question 10

What murmur may be present in AS?

Answer 10

1) Systolic ejection mumur

2) Radiates to the carotids

3) More prominent sitting forward & in expiration (RILE)

Question 11

how does the degree of stenosis affect the murmur in AS?

Answer 11

More severe stenosis = softer murmur

Question 12

Pulse in severe AS?

Answer 12

Slow rising and low volume carotid pulse

Question 13

Pulse pressure in AS?

Answer 13

Narrow

Question 14

Initial investigations in AS?

Answer 14

1) ECG

2) CXR

3) Echo –> diagnostic

Question 15

Mortality rate of moderate to severe AS in symptomatic patients?

Answer 15

as high as 25% in 1 year and 50% in 2 years.

Question 16

What is the definitive treatment for AS? (2)

Answer 16

1) Surgical aortic valve replacement

2) Transcatheter aortic valve implantation

Question 17

What are the indications for surgical treatment in AS? (2)

Answer 17

1) Symptomatic

2) Severe AS

Question 18

What features indicate ‘severe’ AS, and therefore require surgery?

Answer 18

1) aortic jet velocity ≥4 m/s

2) mean trans-valvular pressure gradient ≥ 40 mmHg

3) aortic valve area ≤1 cm2

Question 19

What trans-valvular pressure gradient indicates the need for surgery?

Answer 19

≥40 mmHg

Question 20

What mx option can be used used as a palliative measure for patients that may not be suitable for cardiac surgery or are critically ill in AS?

Answer 20

Percutaneous balloon valvotomy

Note - is also used in children and young adults with congenital AS.

Question 21

Mx of people with mild AS who are asymptomatic?

Answer 21

Conservative management

Question 22

Complications of AS?

Answer 22

1) HF –> due to LVOT obstruction causing LV failure

2) Sudden cardiac death

3) Arrhythmias e.g. AF

4) GI bleeding

5) Endocarditis (more common with congenital bicuspid aortic valve)

Question 23

Why is there an increased risk of GI bleeding in AS?

Answer 23

Von Willebrand multimers get sheared across the narrowed aortic valve as they pass through it with higher velocity.

This prevents them from mediating platelet adhesion at sites of angiodysplasia in the intestine.