Aortic valve disease (aortic stenosis & regurg)

Question 1

What is aortic stenosis?

Answer 1

Narrowing of the orifice of the aortic vale, impeding blood flow.

Question 2

Outline the cause, pathophysiology, signs & symptoms for Aortic stenosis

Answer 2

• Senile calcification (congenital, rheumatic heart disease)
• Impeded blood flow
  
  • Ejection systolic murmur [aortic area, radiates to carotids]
  • Ejection click [pliable valve]
  • Thrill [palp. murmur]
  • **Slow rising pulse **+ narrow pulse pressure [110/90]
  • **Syncope **[fixed cardiac output]
• ⇒ inc AFTERLOAD ⇒ LV hypertrophy
  
  • Heavy non-displaced apex beat
  • LV heave
  • **​Angina - **Inc demand, low supply [low aortic pressure]
  • S4 [stiff ventricles]
• ⇒ inc** End-diastolic LV pressure** & volume
  
  • ⇒ Back pressure ⇒ LA dilatation ⇒ AF & CCF
  • ⇒ LV dilatation ⇒ Failure

Symptoms;

1. Angina [LV hypertrophy + inc afterload]
2. **Syncope **[fixed cardiac output]
3. **CHeart failure **[dilatation]
4. ​Dyspnoea

• Paradoxical/ reverse splitting of 2nd heart sound
  
  • Normally S₂ = A₂…P₂… [P2 moves left on inspiration nearer to A2]
  • S₂ = P₂….A₂… [P2 moves left on inspiration, further from A2]
    
    • LH slowed [Aortic stenosis or LBBB]
    • RH sped [tricuspid regurg (blood can exit RV in 2 places fast)]

Question 3

Outline the investigations for aortic stenosis?

Answer 3

• Echo; diagnostic
• ECG
  
  • LV hypertrophy
  • Blocks
• Doppler echo;
  
  • Estimate pressure gradiant across valve
• Cardiac catheter;
  
  • Valve gradient, LV function, coronary artery disease
  • Emboli risk

Question 4

How would you manage aortic stenosis?

Answer 4

• Prompt valve replacement ideal

Question 5

What is aortic sclerosis?

Answer 5

Senile degeneration of the valve.

Ejection systolic murmur, no carotid radiation & normal pulse & S2

Question 6

What is aortic regurgitation?

Answer 6

The leaking of the aortic valve of the heart causing blood to flow in the reverse direction during ventricular diastole from the aorta into the LV

Question 7

What are the symptoms & signs of aortic regurg?

Answer 7

• Acute; IE, trauma, ascending aortic dissection
• Chronic; Congential, connective tissue disorder, rheumatic fever

Pathophysiology;

• Blood flows back during diastole
  
  • **​Early diastolic murmur **[tricuspid area, sitting forward, expiration & hold]
  • Syncope, CCF
• ⇒** Low diastolic aortic pressure** ⇒** ↑LV SV**
  
  • Angina [↓pressure]
  • **Wide pulse-pressure **[140/140]
  • Collapsing water-hammer pulse
• ⇒ LVH
  
  • ​Displaced, hyperdynamic beat

Symptoms;

• Dyspnoea, orthopnea, PND
• Angina [Coronary perfusion occurs during diastolly, low diastolic aortic pressure due to regurg = low perfusion]
• Syncope, CCF

SIGNS;

• Austin Flint murmur - aortic regurg blocks mitral valve ⇒ mitral stenosis rumbling diastolic murmur
• Corrigan’s sign - carotid pulsation
• de Musset’s sign - head nodding with HR
• Quincke’s sign - capillary pulsations in nail bed
• Duroziez’s sign - finger compressing femoral artery, listen 2cm proximal for systolic murmur, 2cm distal for diastolic murmur
• Traube’s sign - pistol shot sound

Corrigan’s carotid nodded at de Musset while Traube shot his pistol @ Quincke’s nailbed while Duroziez heard a femoral murmur

Question 8

What investigations would you perform for aortic regurg?

Answer 8

• Echo; diagnostic
• ECG;
  
  • LV hypertrophy
• CXR;
  
  • Cardiomegaly, dilated ascending aorta, pulmonary oedema
• Cardiac catheter;
  
  • Assess severity, anatomy & LV function, coronary art disease

Question 9

How do you manage aortic regurg?

Answer 9

Reduce systolic hypertension;

• ACE-i
• Echo every 6-12m to monitor
• Surgical valve replacement if deteriorating