Cardiology #15 (Aortic Valve Diseases)

Question 1

In aortic stenosis, the normal aortic valve opens about 3-4 cm2. In stenosis, how wide does it open?

Answer 1

< 1 cm2

Question 2

Causes of aortic stenosis/etiologies

Answer 2

-Degenerative (calcifications)
- > 70 years of age
- Congenital and Bicuspid aortic valve (instead of having 3 leaflets, it has 2)
-Rheumatic heart disease

Question 3

Explain the murmur of aortic stenosis and WHY it causes those sounds

Answer 3

-Systolic crescendo-decrescendo murmur best heard at RUSB, radiating to carotid artery.
-Ejection click: LV has to push blood harder up through the stenotic valve to open it. Then the murmur is louder with more blood and gets quieter as less blood is in the LV (crescendo-decrescendo)

Question 4

Due to the stenotic aortic valve and the work the LV has to do to push blood up through the valve, what is seen on ECG in aortic stenosis?

Answer 4

Left ventricular hypertrophy

Question 5

An echocardiogram is the best test for aortic stenosis, even though a cardiac catheterization is definitive. True or False?

Answer 5

True

Question 6

Symptoms of aortic stenosis

Answer 6

-Angina (MC symptom)
-Syncope
-CHF
-Weak, delayed carotid pulse (pulsus parvus et tardus)

Question 7

What actions INCREASE the murmur intensity and which DECREASE the murmur intensity of aortic stenosis?

Answer 7

Increase: sitting while leaning forward, squatting, supine, leg raise, expiration
Decrease: Valsalva, standing, inspiration, handgrip

Question 8

Explain what a urinary trait is of a patient with aortic stenosis

Answer 8

-Hemoglobinuria from Microangiopathic Hemolytic Anemia. Damage to the RBC as they pass through the stenotic aortic valve (schistocytes)

Question 9

What is the only effective treatment for aortic stenosis

Answer 9

aortic valve replacement

Question 10

What are the two types of replacement aortic valves for stenosis and when would you use them?

Answer 10

-Mechanical: prolonged durability but thrombogenic. Must be placed on long-term anticoagulant therapy.
-Bioprosthetic: less durable but minimally thrombogenic. Used in patients that cannot be on anticoagulants.

Question 11

What are some bridge therapies that can be used before aortic valve replacement surgery?

Answer 11

-Intraaortic balloon pump
-Percutaneous aortic valvuloplasty

Question 12

What should patients with severe aortic stenosis avoid?

Answer 12

-Avoid physical exertion/venodilators (nitrates)
-Negative inotropes (CCB, BB)

Question 13

Explain the pathophysiology of aortic regurgitation

Answer 13

Incomplete aortic valve closure leads to LV volume overload with eventual LV dilation and heart failure

Question 14

Explain the murmur of aortic regurgitation

Answer 14

Diastolic blowing decrescendo murmur heard best at LUSB (high-pitched).

Question 15

Does amyl nitrate make the murmur of aortic regurgitation better or worse?

Answer 15

Decreases the murmur

Question 16

Name some symptoms of aortic regurgitation (there are MANY different ones with various names)

Answer 16

-Austin Flint Murmur: mid-late diastolic rumble at apex secondary to retrograde competing with flow from LA to LV
-Bounding pulses
-Wide pulse pressure
-Hill’s Sign: popliteal artery systolic pressure > brachial artery by 60 mmHg (most sensitive)
-De Musset’s Sign: head bobbing with each heartbeat
-Quincke’s Pulse: Fingernail bed pulsations with light compression of fingernail bed

Question 17

Definitive diagnostic for aortic regurgitation

Answer 17

Cardiac catheterization

Question 18

Treatment for aortic regurgitation

Answer 18

Medical: after load reduction improves forward flow (ACE, ARB, Nifedipine, Hydralazine)

Surgical: definitive. If symptomatic or EF < 55%