CVPR 04-02-14 10-11am Aortic and Pulmonary Valve Disease - Salcedo

Question 1

Aortic valve anatomy

Answer 1

Aortic root just behind pulmonary artery; Aortic valve in center of heart, behind pulmonic valve & in front of mitral & tricuspid valves…. Three cusps/flaps (left & right where left & right coronary arteriess exit + N?)

Question 2

Aortic Stenosis – mechanism

Answer 2

The mechanism by which a healthy tricuspid aortic valve becomes stenotic is believed to be similar to that of atherosclerosis….. become stenotic in 6th-8th decades of life, mainly caused by calcium deposits in the valve cusps and NOT by fusion of the commissures.

Question 3

Aortic stenosis & Rheumatic fever

Answer 3

Rheumatic fever is very rarely the cause of aortic stenosis in developed countries; when it is, mitral valve is almost always affected as well.

Question 4

Dx of Aortic Stenosis

Answer 4

1. Listen to the patient….. 2. Echocardiogram w/ Doppler interrogation of aortic valve = mainstay of Dx

Question 5

Therapy for Aortic Stenosis

Answer 5

Valve replacement is recommended for individuals w/SYMPTOMATIC SEVERE aortic stenosis (dire prognosis)… may be mechanical or bioprosthetic replacement (can’t repair) – choice depends on age of pt, others [bioprosthesis wears out, so not recommended in young; however, its advantage is that you don’t need warfarin as you would w/a mechanical replacement]

Question 6

Cardinal Symptoms of Severe Aortic Stenosis

Answer 6

Angina, Syncope & Shortness of Breath (HF)….. as soon as symptoms occurs, marked downhill curve in survival

Question 7

Aortic stenosis – cardiac findings

Answer 7

Often cardiac hypertrophy, b/c left ventricle must work harder to get blood out into the aorta

Question 8

Pathophysiology of calcific aortic stenosis

Answer 8

Same risk factors as CAD/atherosclerosis – lipids, HTN, Male gender, Smoking, Diabetes, etc…. proceeds through a process similar to atherosclerosis (cholesterol deposits get calcified)

Question 9

Bernoulli Equation in Echocardiograms

Answer 9

How we measure velocity of red cells … from that estimate pressure gradients through aortic valve (when gradient = ~20, call aortic stenosis) … can also calculate aortic valve area

Question 10

Bicuspid Aortic Valve disease (BAV) – pathophysiology

Answer 10

Two of the three cusps are fused (usually left & right leaflets) = bicuspid instead of tricuspid… Some problem/deficiency with elastic fibers in laminae of aortic media

Question 11

Bicuspid Aortic Valve disease (BAV) – associations

Answer 11

Most common congenital cardiac defect (1-2% of babies)… Can be found in isolation, but often associated w/dilation of proximal ascending aorta secondary to abnormalities of the aortic media.

Question 12

Bicuspid Aortic Valve disease (BAV) – associated problems

Answer 12

After its development, BAV is associated with aortic stenosis, aortic dilation, aneurysms, and dissection… Thus, BAVs should be considered a disease of the entire aortic root.

Question 13

Hereditary Bicuspid Aortic Valve Disease (BAV)

Answer 13

Familial clustering = autosomal dominant inheritance w/reduced penetrance….. Males are affected 4:1….. Echocardiographic screening of first-degree relatives is warranted.

Question 14

Valvular Complications of BAV:

Answer 14

1. Aortic stenosis (AS age 15-65= BAV; AS more rapid in asymetric valves or antero-posterior)….. 2. Aortic Insufficiency (Cusp prolapsed, etc) ….. 3. Predisposition for Endocarditis, esp. in young pts & pts w/AI

Question 15

Vascular Complications of BAV:

Answer 15

1. Aortic dilation….. 2. Aneurysm formation….. 3. Aortic dissection (Coarctaction, PDA, Coronary anomalies)

Question 16

Risk factors for Adverse Cardiac Events in Adutls w/BAV disease

Answer 16

Age 30yrs; Moderate/severe aortic insufficiency; Moderate/severe aortic stenosis

Question 17

Management of BAV

Answer 17

Mild-to-moderate valvular dysfunction & normal LV dimensions/function = Regular echocardiography of aortic valve to evaluate its functional state & measure aortic diameter, chamber dimensions, & ventricular function

Question 18

Other Forms of Aortic Stenosis - Subvalvular disease

Answer 18

1. Thin membrane (the most common lesion), 2. Thick fibromuscular ridge, 3. Diffuse tunnel-like obstruction, 4. Hypertrophic Obstructive Cardiomyopathy, 5. Abnormal mitral valve attachments, and 6. Accessory endocardial cushion tissue

Question 19

Aortic regurgitation – causes of valvular disease

Answer 19

Valvular disease (Rheumatic, Degenerative, Endocarditis, Congenital - Bicuspid/Quadricuspid)

Question 20

Aortic regurgitation – causes of disease of the aorta

Answer 20

Disease of the aorta (Dissection, Marfan’s, Atherosclerosis, Annulo-aortic ectasia, Syphilis, Ankylosing spondilitis, Osteogenesis imperfect)

Question 21

Aortic regurgitation – sound

Answer 21

High pitched, like huff (like mom when she eat hot food…NOT like low pitched blowing out)

Question 22

Signs of aortic regurgitation

Answer 22

Corrigan’s pulse (rapid forceful carotid upstroke followed by rapid decline)… Quincke’s pulse (diastolic blanching in nail bed when slightly compressed)… de Musset’s sign (bobbing of head)… Durozie’s sign (systolic & diastolic femoral bruits when compressed w/stethoscope)… Hill’s sign (systolic BP in legs >30mmHg than in arms)

Question 23

Therapy for aortic insufficiency/regurgitation

Answer 23

Severe AI = surgery (valve replacement)

Question 24

Pulmonic stenosis - when IDed

Answer 24

A common forms of congenital heart disease…. Most pts are children, though pts w/congenital pulmonic stenosis may come to medical attention during adolescence or adulthood

Question 25

Pulmonic stenosis – management

Answer 25

Recently, percutaneous balloon valvuloplasty has largely replaced surgical valvotomy except in pts w/ dysplastic valves