FN: Aortic Stenosis

Question 1

Causes

Answer 1

Senile calcification (60yrs+): commonest
Congenital: Bicuspic valve 40-60rs), Williams syn.
Rheumatic fever

Question 2

Symptoms TRIAD

Answer 2

Angina
Dyspnoea
Syncope (esp. with excercise)

Question 3

Symptoms other

Answer 3

PND, orthopnoea, frothy sputum
Arrhythmias
Systemic emboli if endocarditis
Suddern death

Question 4

Signs

Answer 4

1. Slow rising pulse with narrow PP
2. Aortic Thrill
3. Apex: forceful, non-displaced (pressure overload)
4. Heart sounds
   Quiet A2
   Early syst. ejection click if pliable (young) valve
   S4 (foceful A contraction vs. hypertrophied V)
5. Murmur
   ESM
   Right 2nd ICS
   Sitting forward in end-expiration
   Radiates to carotids

Question 5

Clinical indicators of Severe AS

Answer 5

Quiet/absent A2
S4
Narrow pulse pressure
Decompensation: LVF

Question 6

Differentials

Answer 6

Coronary artery disease
MR
Aortic sclerosis
HOCM

Question 7

Aortic sclerosis

Answer 7

1. Valve thickening: no pressure gradient
2. turbulence –> murmur
3. ESM with no radiation and normal pulse

Question 8

HOCM

Answer 8

ESM murmur whcih increases in intensity with valsalva (AS redcued)

Question 9

Aortic Stenosis

Answer 9

Valve narrow due to fusion of the commissures
Narrow PP, slow rising pulse
Forceful apex
ESM radiating --> carotid
ECG: LVF

Question 10

Aortic Sclerosis

Answer 10

Valve thickening

ESM with no radiation

Question 11

Investigations

Answer 11

Bloods
ECG
CXR
Echo + Doppler
Cardiac Catheterisation + Angiography
Excercise stress Test

Question 12

Bloods

Answer 12

FBC
U+E
Lipids
Glucose

Question 13

ECG

Answer 13

LVH
LV strain: tall R, ST depression, T inversion inV4-V6
LBBB or complete AV block (septal calcification) (may need pacing)

Question 14

CXR

Answer 14

Calcified AV (esp. on lateral films)
LVH
Evidence of failure
Post-stenotic aortic dilatation

Question 15

Echo + Doppler

Answer 15

Diagnostic
Thickened, calcified, immobile valve cusps
Severe AS (AHA/ACC 2006 guidelines)

Question 16

Severe AS (AHA/ACC 2006 guidelines)

Answer 16

Pressure gradient >40mmHg
Jet velocity >4 m/s (or increase by 0.3 m/s ina yr)
Valve area <1 cm2

Question 17

Cardiac Catheterisation + Angiography

Answer 17

Can assess valve gradient and LV function

Assess coronaries in all pts. planned for surgery

Question 18

Excerise Stres test

Answer 18

contraindicated if symptomatic AS

May be useful to assess ex capacity in asympto pts.

Question 19

Management

Answer 19

Medical and Surgical

Question 20

Medical

Answer 20

Optimies RFs: statins, anti-hypertensives, DM
Monitor: regular f/up with echo
Angina: beta - blockers
Heart failure: ACEi and diuretics
Avoid nitrates

Question 21

Prognosis if symptomatic

Answer 21

Poor prognosis if symptomatic
1. Angina/syncope: 2-3 yrs
LVF: 1-2 yrs

Question 22

Indications for valve replacement

Answer 22

Severe symptomatic AS
Severe asymptomatic AS with reduced EF (<50%)
Severe AS undergoing CABG or other valve op

Question 23

Valve types

Answer 23

Mechanical valves lasts longer but need for anticoagulation: young patients

Bioprosthetic dont require anticoagulation but fail sooner

Question 24

Options for unfit patients

Answer 24

Balloon Valvuloplasty - limited use in adults as complications rate is high (>10%) and re-stenosis occurs in 6-12 months

Transcatheter Aortic Valve Implantation (TAVI)

Question 25

TAVI

Answer 25

Folded valve deployed in aortic root
Increased perioperative stroke risk cf. replacement
Decrease major bleeding
Similar survival @ 1 yr
Little long-term data