Clinical: Aortic Valve Disease

Question 1

What are the most common prosthetic heart valves used in aortic valve replacement?

Answer 1

Question 2

• What makes the classic triad of aortic stenosis symptoms?
  
  • What are the associated patient percentages and life expectancies?

Answer 2

Question 3

AORTIC REGURGITATION: SYMPTOMS

• In Chronic Aortic Regurgitation
  
  • What happens to the left ventricle?
  • What happens to the right side of the heart?
    
    • What does this manifest as?
  • What long-term outcomes does this have on a PT?

Answer 3

Question 4

What type of CHF is associated with Paroxysmal nocturnal dyspnea?

What type of CHF is associated with right-sided heart failure (edema)?

Answer 4

Both systolic CHF and Diastolic CHF may result in PND, RHF (edema)

Question 5

• When grading the severity of Aortic Stenosis via an echocardiogram, what two factors are you most concerned with?
  
  • What is the relationship between these two factors

Answer 5

• When peak velocity increases, AVA (area of the vessel) gets smaller.
• Faster peak velocity = worse grade

Question 6

What is the ross procedure?

Answer 6

• The Ross procedure (or pulmonary autograft) is a cardiac surgery operation where a diseased aortic valve is replaced with the person’s own pulmonary valve.

Question 7

What is an Austin-Flint murmur?

Answer 7

Question 8

AORTIC REGURGITATION: PE FINDINGS

• What kind of pules are common?
• What happens to the PMI?
• What kind of murmur is heard, and where?

Answer 8

Question 9

What is the De Musset Sign?

Answer 9

Bobbing of the head with each heartbeat (like a bird walking)

Question 10

AORTIC REGURGITATION: SYMPTOMS

• In Acute Aortic Regurgitation, what can happen to the left side of the heart?
  
  • What conditions does this manifest as?

Answer 10

Question 11

AORTIC REGURGITATION: PE FINDINGS

• What heart sounds are heard, besides the soft, high pitched, early diastolic decrescendo murmur at Erb’s point?
  
  • What are the causes of these sounds?

Answer 11

Question 12

• What Tx do you always avoid when providing medical therapy for aortic stenosis?
• A patient has an inoperable case of aortic stenosis
  
  • What Tx do you use for heart rate control?
  • What Tx do you use for blood volume control?
• What is the goal of medical therapy in aortic stenosis?

Answer 12

Question 13

How do you know the answer?

What causes the Murmor?

What does the systolic ejection fraction indicate?

What treatment should be done?

Answer 13

Question 14

What type of aortic stenosis is described here?

Answer 14

Aortic Stenosis due to Unicuspid/Bicuspid Valve

Question 15

What is the only way to actually improve aortic stenosis?

Answer 15

surgery

Question 16

What valve is this?

Answer 16

Question 17

Aortic Regurgitation

• When do you find Aortic regurge as an isolated lesion?
• What structures are abnormal in Aortic Regurgitation?
• What are the main causes of Aortic Regurgitation? (5)

Answer 17

Question 18

Compare patient outcomes from having a TAVR for 24 months and 5-year post operation

Answer 18

TAVR is better than standard therapy for 24 months then is the same for 5 year outcomes

Question 19

Rank the following operations in order if unadjusted operative mortality (least or greatest)

• Isolated AVR
• AVR + CABG
• AVR + MVR

Answer 19

Question 20

Why does syncope occur that is related to aortic stenosis?

Answer 20

• Syncope = due to physical activity.
  
  • During exercise, blood is shunted to the working muscles.
  • In AS, CO is unable to increase enough to accommodate this decreased TPR.
  • Hypotension occurs and the cerebral perfusion is compromised leading to syncope.

Question 21

What patient population is associated with percutaneous Aortic Balloon Valvuloplasty (PABV) and what is this operation generally used for?

Answer 21

Question 22

What valve is this?

Answer 22

Question 23

What is the law of LAPLACE?

Answer 23

• The larger the vessel radius, the larger the wall tension required to withstand a given internal fluid pressure.
  
  • For a given vessel radius and internal pressure, a spherical vessel will have half the wall tension of a cylindrical vessel.

Question 24

AORTIC VALVE: PATHOBIOLOGY

• Where does blood flow in aortic regurgitation?
• What happens to the left ventricle?
  
  • Why?
• What can acute aortic regurgitation result in? (3)

Answer 24

Question 25

When is the best time to have a surgical intervention on a patient who has aortic stenosis?

Answer 25

* Best time is when AVA is less than 1.0 cm^2 but BEFORE the left ventricle has failed

Question 26

All of these are can be associated with aortic regurgitation? What is a common feature that they all have?

Answer 26

All are associated with increased afterload

Question 27

* When measuring aortic regurgitation Severity using Echocardiography, * What is jet size ratio? * Does it get bigger or smaller when aortic regurgitation gets more severe? * What is regurgitation fraction? * Does it get bigger or smaller when aortic regurgitation gets more severe?

Answer 27

Question 28

* List the Aortic Root abnormalities that are associated with Aortic Regurgitation * What conditions can cause each of the abnormalities?

Answer 28

Question 29

AORTIC STENOSIS: PE FINDINGS 1. What is Pulsus parvus et tardus? 2. Describe the murmor assoicated with Aortic Stenosis (4) * Where is this best heard at? 3. What happens to S2? 4. What other conditions may be found with aortic stenosis?

Answer 29

Question 30

What type of operation is routinely used as part of a Transcatheter Aortic Valve Replacement (TAVR)?

Answer 30

Percutaneous Aortic Balloon Valvuloplasty (PABV)

Question 31

What prosthetic heart valves are used in TAVR?

Answer 31

Question 32

Compare Mechanical Vs. Bioprosthesis Which is better and why?

Answer 32

Mechanical: Better survival rates due to less coagulation

Question 33

Where is Erbs point?

Answer 33

3rd intercostal space on the left

Question 34

What valve is this?

Answer 34

Question 35

What type aortic valve replacement is used in elderly patients with severe, calcific AS who are considered inoperable?

Answer 35

Transcatheter Aortic Valve Replacement (TAVR)

Question 36

* In Tricuspid aortic valves that have aortic stenosis, * What does the stenosis usually arise from? * What are the common risk factors from stenosis? * What age group does this effect? * What is the most common type of stenosis? * How common is this due to Rheumatic Fever?

Answer 36

Question 37

What part of the mitral valve can be affected in aortic regurge if it is severe enough?

Answer 37

Anterior leaflet