AORTIC VALVE DISEASE Flashcards
What are the three forms of aortic stenosis?
Valvular AS
Supravalvular AS
Subvalvular AS
What are the causes of valvular aortic stenosis?
Congenital - most common
Senile calcification
Rheumatic fever
Severe atherosclerosis
What are the causes of subvalvular aortic stenosis?
HOCM
Fibromuscular ring
What are the causes of supravalvular aortic stenosis?
Hypercalcaemia in Williams syndrome
Why is blood supply to the coronary arteries reduced in aortic stenosis patients?
Systole is prolonger and therefore diastole is reduced. The entrance to the coronary arteries is closed during systole. This is particularly a problem because oxygen demand by the myocardium is increased as a result of AS.
What are the symptoms associated with aortic stenosis?
Often patients will be symptomless Dyspnoea - LVF Angina - increased oxygen demand, reduced blood supply Dizziness and syncope Sudden death Systemic emboli
Before doing an exercise test in someone with angina, what must you check that they do not have?
Aortic stenosis can cause sudden death from the mildest exertion.
On examination, what signs might be found in someone with aortic stenosis?
Ejection-systolic murmur Slow rising, small volume pulse - best felt at carotid Low BP Heavy apex beat - rarely displaced Murmur radiates to the carotids Palpable thrill Signs of LVF
What investigations would you order for someone with suspected aortic stenosis?
ECG
Echo
Chest x-ray
Cardiac catheterisation
What would the ECG of someone with aortic stenosis show?
Left ventricular hypertrophy - tall R wave in V5, deep S wave in V2, T wave inversion in lateral leads
What might a chest x-ray of someone with aortic stenosis show?
Enlarged cardiac shadow
Calcified valve
Pulmonary oedema
When would you use cardiac catheterisation in someone with aortic stenosis?
To provide information on valve gradient and assess coronary artery disease
What is the medical management of someone with aortic stenosis? What do we definitely not give?
Diuretics to treat the heart failure
ACE inhibitors are contraindicated in patients with aortic stenosis because they may have a negative ionotropic effect and result in acute pulmonary oedema.
Antianginals may cause profuse hypotension in patients
What is the surgical management of someone with aortic stenosis?
Valve replacement - Considered in all symptomatic patients with marked stenosis (aortic valve gradient >50 mmHg)
Valvulolpasty - only really considered in younger patients
What is the prognosis for someone with symptomatic aortic stenosis who declines surgical treatment?
50% 2 year survival
What are the two anatomical causes of aortic regurgitation?
Abnormality of valve cusps
Dilatation of the aortic root and valve ring
What are the causes of valve disease aortic regurgitation (as opposed to aortic root disease)?
Congenital Rheumatic fever Infective endocarditis Rheumatoid arthritis SLE Connective tissue disease - Marfan syndrome, pseudoxanthoma elasticium
What are the causes of aortic root disease aortic regurgitation (as opposed to valve disease)?
Marfan syndrome Osteogenesis imperfecta Type A aortic dissection Ankylosing spondylitis Reiter's syndrome Psoriatic arthritis
What are the cardiac complications of aortic regurgitation?
Increase end-diastolic volume and therefore increased stroke volume leads to hypertrophy, followed by LVF. This may cause pulmonary hypertension and RVF (this is uncommon).
What are the symptoms associated with aortic regurgitation?
Often asymptomatic
Dyspnoea if severe
On examination, what signs might be found in someone with aortic regurgitation?
Early diastolic murmur
Collapsing pulse
Wide pulse pressure
Downward and laterally displaced apex beat
Murmur best heard at left lower sternal edge with patient sitting forward
May be ejection systolic murmur due to increased stroke volume despite no stenosis
Signs of LVF
Musset’s sign - head bobs with each beat
Corrigan’s sign - prominent pulsation in neck
Quincke’s sign - capillary pulsation in nail bed
Pistol shot femoral arteries - audible femoral sound
Duroziez’s sign - also femoral sound, to and fro sound
What investigations would you order in someone with suspected aortic regurgitation?
ECG
Chest X-ray
Echo
Cardiac catheterisation
What would ECG of someone with aortic regurgitation show?
Enlarged left ventricle
Why might you use cardiac catheterisation in someone with aortic regurgiation?
Assess aortic root size
