AORTIC VALVE DISEASE

Question 1

What are the three forms of aortic stenosis?

Answer 1

Valvular AS
Supravalvular AS
Subvalvular AS

Question 2

What are the causes of valvular aortic stenosis?

Answer 2

Congenital - most common
Senile calcification
Rheumatic fever
Severe atherosclerosis

Question 3

What are the causes of subvalvular aortic stenosis?

Answer 3

HOCM

Fibromuscular ring

Question 4

What are the causes of supravalvular aortic stenosis?

Answer 4

Hypercalcaemia in Williams syndrome

Question 5

Why is blood supply to the coronary arteries reduced in aortic stenosis patients?

Answer 5

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.

Question 6

What are the symptoms associated with aortic stenosis?

Answer 6

Often patients will be symptomless
Dyspnoea - LVF
Angina - increased oxygen demand, reduced blood supply
Dizziness and syncope
Sudden death
Systemic emboli

Question 7

Before doing an exercise test in someone with angina, what must you check that they do not have?

Answer 7

Aortic stenosis can cause sudden death from the mildest exertion.

Question 8

On examination, what signs might be found in someone with aortic stenosis?

Answer 8

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

Question 9

What investigations would you order for someone with suspected aortic stenosis?

Answer 9

ECG
Echo
Chest x-ray
Cardiac catheterisation

Question 10

What would the ECG of someone with aortic stenosis show?

Answer 10

Left ventricular hypertrophy - tall R wave in V5, deep S wave in V2, T wave inversion in lateral leads

Question 11

What might a chest x-ray of someone with aortic stenosis show?

Answer 11

Enlarged cardiac shadow
Calcified valve
Pulmonary oedema

Question 12

When would you use cardiac catheterisation in someone with aortic stenosis?

Answer 12

To provide information on valve gradient and assess coronary artery disease

Question 13

What is the medical management of someone with aortic stenosis? What do we definitely not give?

Answer 13

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

Question 14

What is the surgical management of someone with aortic stenosis?

Answer 14

Valve replacement - Considered in all symptomatic patients with marked stenosis (aortic valve gradient >50 mmHg)

Valvulolpasty - only really considered in younger patients

Question 15

What is the prognosis for someone with symptomatic aortic stenosis who declines surgical treatment?

Answer 15

50% 2 year survival

Question 16

What are the two anatomical causes of aortic regurgitation?

Answer 16

Abnormality of valve cusps

Dilatation of the aortic root and valve ring

Question 17

What are the causes of valve disease aortic regurgitation (as opposed to aortic root disease)?

Answer 17

Congenital 
Rheumatic fever
Infective endocarditis
Rheumatoid arthritis
SLE
Connective tissue disease - Marfan syndrome, pseudoxanthoma elasticium

Question 18

What are the causes of aortic root disease aortic regurgitation (as opposed to valve disease)?

Answer 18

Marfan syndrome
Osteogenesis imperfecta
Type A aortic dissection
Ankylosing spondylitis
Reiter's syndrome
Psoriatic arthritis

Question 19

What are the cardiac complications of aortic regurgitation?

Answer 19

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).

Question 20

What are the symptoms associated with aortic regurgitation?

Answer 20

Often asymptomatic

Dyspnoea if severe

Question 21

On examination, what signs might be found in someone with aortic regurgitation?

Answer 21

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

Question 22

What investigations would you order in someone with suspected aortic regurgitation?

Answer 22

ECG
Chest X-ray
Echo
Cardiac catheterisation

Question 23

What would ECG of someone with aortic regurgitation show?

Answer 23

Enlarged left ventricle

Question 24

Why might you use cardiac catheterisation in someone with aortic regurgiation?

Answer 24

Assess aortic root size