Aortic valve disease

Question 1

What is aortic regurgitation (AR)?

Answer 1

Aortic regurgitation (AR) is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole.

Question 2

What are the causes of aortic regurgitation due to valve disease?

Answer 2

Causes of AR due to valve disease include rheumatic fever, calcific valve disease, connective tissue diseases (e.g. rheumatoid arthritis/SLE), and bicuspid aortic valve.

Question 3

What are the causes of aortic regurgitation due to aortic root disease?

Answer 3

Causes of AR due to aortic root disease include spondylarthropathies (e.g. ankylosing spondylitis), hypertension, syphilis, Marfan’s syndrome, and Ehler-Danlos syndrome.

Question 4

What are the acute causes of aortic regurgitation?

Answer 4

Acute causes of AR include infective endocarditis and aortic dissection.

Question 5

What are the features of aortic regurgitation?

Answer 5

Features include an early diastolic murmur, collapsing pulse, wide pulse pressure, Quincke’s sign, and De Musset’s sign.

Question 6

What is the significance of the mid-diastolic Austin-Flint murmur in severe AR?

Answer 6

The mid-diastolic Austin-Flint murmur in severe AR is due to partial closure of the anterior mitral valve cusps caused by the regurgitation streams.

Question 7

How should suspected aortic regurgitation be investigated?

Answer 7

Suspected AR should be investigated with echocardiography.

Question 8

What is the management for aortic regurgitation?

Answer 8

Management includes medical management of any associated heart failure and surgery for symptomatic patients with severe AR or asymptomatic patients with severe AR who have LV systolic dysfunction.

Question 9

What are the clinical features of symptomatic aortic stenosis?

Answer 9

Chest pain, dyspnoea, syncope/presyncope (e.g. exertional dizziness), and murmur.

An ejection systolic murmur (ESM) is classically seen in aortic stenosis and classically radiates to the carotids. This is decreased following the Valsalva manoeuvre.

Question 10

What are the features of severe aortic stenosis?

Answer 10

Narrow pulse pressure, slow rising pulse, delayed ESM, soft/absent S2, S4, thrill, duration of murmur, and left ventricular hypertrophy or failure.

Question 11

What are the common causes of aortic stenosis?

Answer 11

Degenerative calcification (most common in older patients > 65 years), bicuspid aortic valve (most common in younger patients < 65 years), William’s syndrome (supravalvular aortic stenosis), post-rheumatic disease, and subvalvular (HOCM).

Question 12

What is the management for asymptomatic aortic stenosis?

Answer 12

If asymptomatic, then observe the patient as a general rule.

Question 13

What is the management for symptomatic aortic stenosis?

Answer 13

If symptomatic, then valve replacement is indicated. If asymptomatic but valvular gradient > 40 mmHg with features such as left ventricular systolic dysfunction, consider surgery.

Question 14

What are the options for aortic valve replacement (AVR)?

Answer 14

Surgical AVR is the treatment of choice for young, low/medium operative risk patients. Transcatheter AVR (TAVR) is used for patients with high operative risk. Balloon valvuloplasty may be used in children with no aortic valve calcification and in adults limited to patients with critical aortic stenosis who are not fit for valve replacement.

Question 15

What is a bicuspid aortic valve?

Answer 15

A congenital heart defect occurring in 1-2% of the population, usually asymptomatic in childhood.

Question 16

What complications are associated with a bicuspid aortic valve?

Answer 16

The majority of patients eventually develop aortic stenosis or regurgitation, and there is a higher risk for aortic dissection and aneurysm formation of the ascending aorta.

Question 17

What is the association of bicuspid aortic valve with coronary circulation?

Answer 17

It is associated with a left dominant coronary circulation, where the posterior descending artery arises from the circumflex instead of the right coronary artery.

Question 18

What genetic condition is associated with bicuspid aortic valve?

Answer 18

Turner’s syndrome.

Question 19

What percentage of patients with a bicuspid aortic valve also have coarctation of the aorta?

Answer 19

Around 5% of patients.

Question 20

What are the most common heart valves that need replacing?

Answer 20

The aortic and mitral valves.

Question 21

What are the two main options for heart valve replacement?

Answer 21

Biological (bioprosthetic) valves and mechanical valves.

Question 22

What is the origin of biological (bioprosthetic) valves?

Answer 22

Usually bovine or porcine in origin.

Question 23

What is a major disadvantage of biological (bioprosthetic) valves?

Answer 23

Structural deterioration and calcification over time.

Question 24

Which patients typically receive bioprosthetic valves?

Answer 24

Most older patients (> 65 years for aortic valves and > 70 years for mitral valves).

Question 25

Is long-term anticoagulation usually needed for bioprosthetic valves?

Answer 25

No, long-term anticoagulation is not usually needed.

Question 26

What anticoagulant may be given for the first 3 months after receiving a bioprosthetic valve?

Answer 26

Warfarin may be given for the first 3 months depending on patient factors.

Question 27

What is given long-term to patients with bioprosthetic valves?

Answer 27

Low-dose aspirin.

Question 28

What is the most common type of mechanical valve now implanted?

Answer 28

The bileaflet valve.

Question 29

What is a major disadvantage of mechanical valves?

Answer 29

Increased risk of thrombosis, meaning long-term anticoagulation is needed.

Question 30

What anticoagulant is preferred for patients with mechanical heart valves?

Answer 30

Warfarin is still used in preference to DOACs.

Question 31

When is aspirin normally given to patients with mechanical valves?

Answer 31

Only in addition if there is an additional indication, e.g., ischaemic heart disease.

Question 32

What is the target INR for aortic valves?

Answer 32

3.0.

Question 33

What is the target INR for mitral valves?

Answer 33

3.5.

Question 34

Are antibiotics recommended for prophylaxis of endocarditis for common procedures?

Answer 34

No, antibiotics are no longer recommended for common procedures such as dental work.