Aortic valve disease Flashcards
What is aortic regurgitation (AR)?
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.
What are the causes of aortic regurgitation due to valve disease?
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.
What are the causes of aortic regurgitation due to aortic root disease?
Causes of AR due to aortic root disease include spondylarthropathies (e.g. ankylosing spondylitis), hypertension, syphilis, Marfan’s syndrome, and Ehler-Danlos syndrome.
What are the acute causes of aortic regurgitation?
Acute causes of AR include infective endocarditis and aortic dissection.
What are the features of aortic regurgitation?
Features include an early diastolic murmur, collapsing pulse, wide pulse pressure, Quincke’s sign, and De Musset’s sign.
What is the significance of the mid-diastolic Austin-Flint murmur in severe AR?
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.
How should suspected aortic regurgitation be investigated?
Suspected AR should be investigated with echocardiography.
What is the management for aortic regurgitation?
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.
What are the clinical features of symptomatic aortic stenosis?
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.
What are the features of severe aortic stenosis?
Narrow pulse pressure, slow rising pulse, delayed ESM, soft/absent S2, S4, thrill, duration of murmur, and left ventricular hypertrophy or failure.
What are the common causes of aortic stenosis?
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).
What is the management for asymptomatic aortic stenosis?
If asymptomatic, then observe the patient as a general rule.
What is the management for symptomatic aortic stenosis?
If symptomatic, then valve replacement is indicated. If asymptomatic but valvular gradient > 40 mmHg with features such as left ventricular systolic dysfunction, consider surgery.
What are the options for aortic valve replacement (AVR)?
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.
What is a bicuspid aortic valve?
A congenital heart defect occurring in 1-2% of the population, usually asymptomatic in childhood.
What complications are associated with a bicuspid aortic valve?
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.
What is the association of bicuspid aortic valve with coronary circulation?
It is associated with a left dominant coronary circulation, where the posterior descending artery arises from the circumflex instead of the right coronary artery.
What genetic condition is associated with bicuspid aortic valve?
Turner’s syndrome.
What percentage of patients with a bicuspid aortic valve also have coarctation of the aorta?
Around 5% of patients.
What are the most common heart valves that need replacing?
The aortic and mitral valves.
What are the two main options for heart valve replacement?
Biological (bioprosthetic) valves and mechanical valves.
What is the origin of biological (bioprosthetic) valves?
Usually bovine or porcine in origin.
What is a major disadvantage of biological (bioprosthetic) valves?
Structural deterioration and calcification over time.
Which patients typically receive bioprosthetic valves?
Most older patients (> 65 years for aortic valves and > 70 years for mitral valves).
Is long-term anticoagulation usually needed for bioprosthetic valves?
No, long-term anticoagulation is not usually needed.
What anticoagulant may be given for the first 3 months after receiving a bioprosthetic valve?
Warfarin may be given for the first 3 months depending on patient factors.
What is given long-term to patients with bioprosthetic valves?
Low-dose aspirin.
What is the most common type of mechanical valve now implanted?
The bileaflet valve.
What is a major disadvantage of mechanical valves?
Increased risk of thrombosis, meaning long-term anticoagulation is needed.
What anticoagulant is preferred for patients with mechanical heart valves?
Warfarin is still used in preference to DOACs.
When is aspirin normally given to patients with mechanical valves?
Only in addition if there is an additional indication, e.g., ischaemic heart disease.
What is the target INR for aortic valves?
3.0.
What is the target INR for mitral valves?
3.5.
Are antibiotics recommended for prophylaxis of endocarditis for common procedures?
No, antibiotics are no longer recommended for common procedures such as dental work.
