L11 - Chronic Aortic Valve Disease Flashcards
Does aortic stenosis or aortic regurg have symptoms of:
- angina
- SOB
- Syncope
AS
Does aortic stenosis or aortic regurg have symptoms of:
- angina
- Exertional SOB
- Fatigue
AR
Also: Palpitations (due to awareness of the dilated, hyperdynamic left ventricle); Inappropriate sweating; Syncope is unusual in contrast to aortic stenosis
Does aortic stenosis or aortic regurg have exam findings of:
- delayed carotid upstroke
- non-displaced but more forceful apical impulse often with “a” kick
- long ejection murmur at base to carotids and precordium
AS
BP normal or decreased pulse pressure
1. Small volume carotid pulse with sustained upstroke (pulsus parvus et tardus),
occasionally with shudder.
2. Pulse will show these characteristics due to the slow rate of ejection of blood
into the aorta secondary to the obstruction at the valve even in the absence of a
decreased stroke volume.
3. In the elderly, the pulse pressure may be wide and the carotid upstroke normal
due to a stiff, non-compliant aorta.
C. Auscultation
1. S2A absent or decreased (no S2 heard at apex) reflecting calcification of valve.
In middle aged to elderly adult, rare to have severe stenosis wo severe calcification.
2. Crescendo-decrescendo (“diamond shaped”) systolic murmur at base radiating
to carotids and across precordium to apex; may feel thrill at base or suprasternal
notch. The length and loudness of murmur correlates with the gradient.
3. May have brief murmur of aortic regurgitation.
Does aortic stenosis or aortic regurg have exam findings of:
- wide pulse pressure with low diastolic pressure
- hyperdynamic carotid pulse
- hyperdynamic and leftward displaced apical impulse
- high freq diastolic murmur along sternal border
AR
A. Signs of a hyperkinetic pulse
1. Widened pulse pressure (In addition, with severe AR, Korotkoff sounds may
be heard all the way down to nearly 0 mm Hg. In this case, the best estimate of
the true diastolic blood pressure is the pressure at the time of the muffling of the
Korotkoff sounds)
2. Carotids brisk (“Waterhammer”), visibly pulsatile (“Corrigan pulse”) and may
be bisferiens.
3. Femoral pistol shots
4. Duroziez’s sign
B. LV apical impulse brisk, enlarged and displaced down & out
(the width of the pulse pressure & the degree of LV apical displacement are excellent
indices of the amount of chronic aortic regurgitation. Why?)
C. Auscultation
1. High frequency diastolic decrescendo murmur along left sternal border (right
sternal border when AR d/t disease of aorta). The longer the murmur, the greater
the amount of chronic regurgitation.
2. Austin Flint murmur simulates mitral stenosis murmur
Does aortic stenosis or aortic regurg have EKG findings of LVH?
Both
Does aortic stenosis or aortic regurg have CXR findings of enlarged LV with apex displaced down and out.
AR: A marked dilatation of ascending aorta may also suggest aortic root disease as the cause of the AR
AS: CXR- cardiac size normal or at most slightly increased; post-stenotic dilatation
of aorta may be seen; sometimes aortic valve calcium evident.
For which is echo:
- the best non-invasive test for assessing severity and effect of this valvular defect; can measure gradient across valve and accurately assess hypertrophy.
- very helpful to estimate severity & LV size and function.
- AS
2. AR
Etiology of AS
A. Congenital
1. unicuspid or dome-shaped (children)
2. bicuspid with calcification later causing severe stenosis at 30-65 y/o
B. Rheumatic
C. Degenerative (senile) calcific (most common form in people > 65-70 y/o)
Valvular defect involving narrowing of the valve orifice (reduced cross-sectional area of the opened valve) that is usually caused by a thickening and increased rigidity of the valve leaflets, often accompanied by calcification.
AS
In this valve defect, the valve does not open completely as blood flows across it, thereby resulting in a high resistance to flow and the development of a large pressure gradient across the valve when blood is flowing through the valve. In other words, pressure increases in the chamber proximal to the valve and decreases in the chamber or artery distal to the valve.
AS - Aortic valve is between the LV and aorta so pressure increases in the LV –> LV hypertrophy
This valvular defect occurs when the valve leaflets do not completely seal when the valve is closed, causing backward flow of blood into the proximal chamber.
AR - regurgitation from the aorta into the LV after ventricular ejection
Etiology of AR
A. Diseases affecting the aortic valve
1. Rheumatic
2. Congenital bicuspid valve
3. Endocarditis (but usually causes acute AR)
B. Diseases affecting the aorta itself (e.g. dilatation) and thus causing AR
1. Annuloaortic ectasia
2. Bicuspid aortopathy
2. Connective tissue diseases (e.g. Marfan’s disease) even without dissection of
aorta
3. Dissecting aortic aneurysm (with or without connective tissue disorder)
4. Various inflammatory arthritic syndromes (e.g. seronegative
spondyloarthropathies).
5. Syphilis
Which valve defect results in thick and stiff LV but NOT dilated?
AS
How does hypotension result from AS?
because of stiffness, LV diastolic filling is quite dependent on a
properly timed, strong atrial contraction; therefore, disruption of this by such
heart rhythm disturbances such as atrial fibrillation or atrioventricular dissociation
(e.g. 3rd degree atrioventricular block) may lead to significant hypotension.
Define pulse pressure
the difference between the systolic and diastolic pressure readings. It is measured in millimeters of mercury (mmHg). It represents the force that the heart generates each time it contracts. If resting blood pressure is (systolic/diastolic) 120/80 millimeters of mercury (mmHg), pulse pressure is 40.
