Babaliaros - Valvular heat disease Aortic Stenosis

Question 1

Describe what you would see with pressure measurements between aorta and left ventricle with aortic stenosis

Answer 1

• you get a wide pulse pressure, as there is a lare discrepancy between peak pressure of LV and peak pressure of aorta

Question 2

What is babaliaros’s rule for determing severity of aortic stenosis

Answer 2

in critically severe AS, Mean gradient is greater than or equal to ejection fraction

Question 3

How do you measure velocity across the aortic valve?

Answer 3

• ultrasound (echo)

Question 4

For valve area, give area that would indicate:

• mild AS
• moderate AS
• severe AS

Give same values for mean gradient

Answer 4

• greater than 1.5 cm squared
  1.0-1.5 cm squared
  <1.0 cm squared

less than 25
25-40
greater than 40

Question 5

name symptoms of AS

Answer 5

1. dyspnea (especially with exertion)
2. chest pain (anginal type)
3. syncope or presyncope (HYPOTENSION)
4. Fatigue (Elderly complaint)
5. palpitations

Question 6

Describe braunwald’s graph of AS

Answer 6

• Long latent period as you get incerased obstruction and myocardial overload
• onset of severe symtoms leads to drastic decrease in survival percentage leading to an earlier death

Question 7

Apply 5 finger exam to AS

Answer 7

1. MURMUR (systolic ejection)
2. may radiate to carotids
3. evaluate for edema
4. anemia/GI bleed
5. evaluate for associated comorbidities

Question 8

describe AS murmur

Answer 8

• systolic ejection murmur
• harsh
• heard best at upper sternal border or at apex
• crescendo descrendo
• decreases the S2 sound

Question 9

Give the stepwise process of aortic stenosis pathophysiologically

Answer 9

1. changes in left ventricular function due to a left ventricular pressure overload (hypertrophic remodeling)
2. hypertrophic remodeling leads to DIASTOLIC DYSFUNCTION
3. you get increased afterload because of stenosis too; this eventually results in decreased ejection fraction (systolic dysfunction)
4. CO decreases- look out for arrythmias and blocks
5. Incrased myocardial oxygen needs due to hypertoophy that compresses the coronary arteries; you also can get reduced diastolic filling-induced angina, even if you don’t have coronary artery dsease

Question 10

What are EKG findings for AS

Answer 10

• LVH causes ST-T changes

Question 11

4 treatment options for AS

Answer 11

1. medical management
2. Surgical aortic valve replacement (SAVR)
3. balloon aortic valvuloplasty
4. transcatheter aortic valve replacement

Question 12

T/F: we can use medications to prevent or treat AS

Answer 12

F; we can just ease symptoms with meds; the only way to eliminate AS is to mechanically restore flow

Question 13

how does SAVR work

Answer 13

1. cut open chest and place patietn on cardiopulm bypass
2. excise the old valve, put the new one in
3. take off bypass and close up

Question 14

indications of SAVR

Give 3 examples of big recommendations (class 1 indications)

Answer 14

• symptomatic and severe AS; not with those who are asymptomatic (risks of surgery outweigh the risk of sudden death)
  1. severe high gradient AS who have symptoms by history or on exercise testing
  2. asymptomatic patients with AS and LVEF < 50 percent
  3. patients with severe AS when undergoing other cardiac surgery ( chance find)

Question 15

Give the two main valve choices

Answer 15

1. mechanical valve (plastic, carbon, or metal)

2. biological valve ( animal tissue or human tissue

Question 16

When would you use mechanical valves?

pros and cons

Answer 16

• younger patients (< 65)
• benefits: strong, last a long time
• cons: coumadin.. it cliks

Question 17

Pros of biological valves? cons? indication

Answer 17

• use biological valve with patients >65 yo
  pro: no coumadin
• cons: shorter lifespan of valve (10-15 years)

Question 18

name some limitations of surgical therapy

Answer 18

hostile chest – secondary to radiation

Question 19

Describe logic of BAV

Answer 19

• balloon aortic valvuloplasty
• increase the pace of hte heart (200-220/min) to cause hypotension to essentially stop all blood pressure–> stretch the valve to last for 6 months to a year

Question 20

how does stented valve work? do you remove the stenotic valve?

Answer 20

• put in a balloon with a stent to keep the oLD aortic valve open; the diseases valve is used as a support to anchor the stent

Question 21

what forces must be provided by the stented valve? why?

Answer 21

• high radial force in order to expand within the aortic valve and keep it open

Question 22

Name delivery approaches for transcatheter valve replacement

Answer 22

1. transfemoral
2. transapical
3. transcaval

Question 23

result of TAVR on mortality and stroke risk

Answer 23

Decrease