Aortic valve disease (CVS)

Question 1

Define aortic stenosis

Answer 1

Narrowing and tightening of the aortic valve leading to reduced blood flow from the left ventricle into the aorta and ultimately to the rest of the body.
It is the most common valve disease (in europe)
It leads to left vent outflow tract obstruction (LVOTO) which eventually leads to left vent failure

Question 2

What are the risk factors of aortic stenosis?

Answer 2

Age, CKD, hypertension, diabetes

Question 3

What is the commonest cause and aetiology in aortic stenosis in elders (>65 years)?

Answer 3

Degenerative calcifcation
Most common cause of AS in older patients

Question 4

What is the most common cause of aortic stenosis in young patients (<65 yrs)?

Answer 4

Congenital bicuspid valve

Question 5

What are the causes/aetiology of aortic stenosis?

Answer 5

Degenerative calcification - age related
Congenital bicuspid aortic valve
Rheumatic heart disease
William’s syndrome (supravalvular aortic stenosis)

Question 6

What are the symptoms of mild aortic stenosis?

Answer 6

Like all valve diseases, mild to moderate may be asymptomatic and may be picked up by chance during cardiac ausc or an echo

Question 7

What are the signs of severe aortic stenosis?

Answer 7

Severe AS symptoms: Syncope (exertional), Angina/chest pain, dyspnea (SAD)

Also - pre-syncope, palpitations, left vent heart failure symptoms (exertional dyspnea, orthopnea, PND)

Question 8

What are the clinical signs of aortic stenosis?

Answer 8

Narrow pulse pressure
Slow rising carotid pulse
Heaving apex beat (if there is left vent hypertrophy, may be displaced)
Ejection systolic murmur, radiating to the carotids + sounds ‘harsh’.
Soft/absent S2
S4 sound

Question 9

What are the differentials for aortic stenosis?

Answer 9

CAD
HF
Arrhythmias
Other valvular diseases

Question 10

What are the investigations for aortic valve stenosis?

Answer 10

Transthoracic Echo - definitive diagnosis
ECG - see if LV hypertrophy
CXR - cardiomegaly, evidence of pulm oedema, calcified valv

most of the severe cases have LV hypertrophy

Question 11

What is the definitive investigation test for aortic stenosis?

Answer 11

Transthoracic echo

This gives a definitive diagnosis as it assesses left vent function and thickness, flow status and valve. It assesses its severity.
Looks at: aortic valve area and pressure gradient for narrowing, LV hypertrophy, overall vent function

Question 12

What is the criteria for severe aortic stenosis?

Answer 12

Peak gradient>40mmHg
Valve area < 1.0cm^2
Aortic jet velocity >4m/s
^ on the echo
However, in severe left vent dysfunction, it may show a low peak gradient which can be falsely reassuring

Question 13

How does aortic stenosis develop/aetiology, and its pathphysiology?

Answer 13

The narrowing is usually due to valve fibrosis and calcification (80%)

1. Fibrosis as well as calcification due to calcium accumulation
2. The valves get thicker, less mobile, less area -> leads to increased pressure gradient across the aortic valve during ejection as LV needs to produce higher pressure
3. There is incr afterload due to valve narrowing/stiff causing LV hypertrophy. Overtime this leads to diastolic dysfunction (bc can’t relax properly)
4. Eventually this may lead to LV HF if untreated

Question 14

What is the management if the aortic stenosis patient is asymptomatic?

Answer 14

Asymp dont usually need treatment.
Patients who do not meet the criteria for intervention should have regular echocardiography follow-up (mild to moderate = yearly)
However, if they are asymp but have valvular gradient>40mmHg, consider surgery

Question 15

What are the indications for surgical treatment in aortic stenosis?

Answer 15

All symptomatic pts.

Asymp pts but valvular gradient>40mmHg and with features like LV systolic dysfunction. - consider surgery

Question 16

What are the types of surgical intervention for aortic stenosis and which pts for which?

Answer 16

Transcatheter aortic valve implantation (TAVI) - used for pts with high operative risk (so older pts, severe co mobidities, frailty)

Surgical aortic valve replacement - treatment choice for young, low risk pts.
Balloon valvuloplasty - for children with no aortic valve calcification. in adults, limited to pts not fit for valve replacement (contraindicated ig)

Question 17

What is the medical management for aortic stenosis?

Answer 17

Doesn’t really improve AS outcome and mainly used if surgery is not an option
These are HF meds - ACEi, beta blockers, diuretics.

Question 18

What are the complications of aortic stenosis?

Answer 18

HF, pulm hypertension, Sudden death, arrhythmias, GI bleed, endocarditis

Question 19

Define aortic valve regurgitation and how it is classified

Answer 19

Where the aortic valve fails to close properly, leading to the back flow of blood into the left ventricle during diastole.
Acute aortic regurgitation
Chronic aortic regurgitation

Question 20

What are the risk factors of aortic regurgitation?

Answer 20

Age, Male, congenital aortic valve/root defects (bicuspid aortic valve, marfan’s syndrome)

Question 21

What are the differentials for aortic regurgitation?

Answer 21

Mitral regurgitation
Aortic stenosis
Pulmonary regurgitation

Question 22

How does aortic regurg work?

Answer 22

Normally the valve closes tightly at the end of systole. However, here the valve leaflets fail to close tightly due to valve/aortic root disease.

Question 23

What are the causes of aortic regurgitation (aetiology)?

Answer 23

Causes are either due to:

Valve disease
- Rheumatic heart disease/fever
- Calcific valve
- Infective endocarditis
- Congenital bicuspid aortic valve

Aortic root disease/dilation
- Aortic dissection
- Spondylarthropathies e.g. anky spond
- Connective tissue diseases (marfan’s syndrome, ehler-danlos syndrome)
- Syphilis

Question 24

What are the clinical features specifically of acute aortic regurg?

Answer 24

Sudden cardiovasc collapse
Acute pulm oedema - SOB, sweating, pallor, peripheral vasoconstriction

Question 25

What are the clinical features specifically of chronic aortic regurg?

Answer 25

Insidious slower onset, exertional dyspnea, orthopnea, PND, stable angina even in absence of CAD (due to reduction in diastolic coronary perfusion)

Question 26

What are the (most likely) causes of acute aortic regurg?

Answer 26

Infective endocarditis, aortic dissection

Question 27

What are the common clinical signs of aortic regurg?

Answer 27

• Early diastolic murmur (heard in aortic region (or left sternal edge) on exhalation when patient is leaning forward)
• Collapsing pulse
• Wide pulse pressure
• De musset’s sign (head nodding with heart beat)
• Quincke’s sign (pulsation of nailbed)
• Austin-Flint murmur (‘rumbling’ murmur heard at apex caused by back flow hitting the MV -> vibrate)
• Soft S1 sound

Question 28

What are the investigations of aortic regurg?

Answer 28

TT Echo - gives definitive diagnosis, Can visualise the origin of the regurg and its width
Observations (widened pulse pressure)
Throat swab for strep A
ECG (LV hypertrophy)
Bloods - infective endocarditis
Cardiac MRI - LVH
Invasive Cardiac catheterisation and angiography (used when non-invasive tests are inconclusive) - assess severity, see if LVH, shows dimensions of aortic root

Question 29

What is the management of aortic regurg if asymptomatic?

Answer 29

Monitor LV diameters or systolic function

Question 30

What is the medical management of aortic regurg?

Answer 30

Beta blockers and or losartan to lower systolic hypertension

Question 31

What are the indications for surgical management for aortic regurg?

Answer 31

Symptomatic AR
Asymp AR with poor LVEF (<=50%), diastolic diameter >70mm or end systolic diameter >50mm.
Infective endocarditis refractory to medical therapy
Significant enlargement of ascending aorta

Question 32

What are the complications of aortic regurg?

Answer 32

Acute AR can lead to cardiovascular collapse and de novo acute heart failure.

Chronic AR that is not treated -> chronic heart failure with predominantly left ventricular symptoms (pulm oedema).