L30 Flashcards
What are 3 causes of aortic stenosis? What does each tell you about the patient?
Rheumatic - scarring
Congenital bicuspid valve (calcify over time) - young pts
Calcification - older pts
Pathophys of aortic stenosis
LV must pump harder to get through the valve - generate higher SYSTOLIC pressures to open it
Lead to LV hypertrophy
- ↑LV EDP
Can cause angina with ↑cardiac demand
What are the 3 clinical symptoms that aortic stenosis can present as?
HF - if this is your stenosis presentation, most likely to have worst outcome
Angina
Syncope = can’t ↑CO w/ exercise, associated with ventricular arrhythmia
What is the progression of aortic stenosis throughout life?
Long latent period
Until sudden onset of severe symptoms
Fast death
S2 heart sound
Aortic valve closes
S1 heart sound
Mitral valve closes
Sounds for aortic stenosis
Whooshing between S1-S2 = pressure gradient across the aortic valve
You’re hearing high velocity flow
JETS!!!
What sound specifically suggests a bicuspid valve
Ejection click right after S1 = bicupsid
+/1 whooshing of aortic stenosis depending on how calcified the valve is
What is the carotid artery pulsation for aortic stenosis?
Pulsus parvus et tardus
What does an S4 heart sound mean?
“Atrial gallop” // apical impulse
Still LV due hypertrophy from ↑LV P
The ↑P is being reflected onto atria -> LA contracting forcefully
(More common cause = HTN)
When do you hear S4 heart sound? What does it sound like?
Right before S1
“A stiff wall”
In total, what are the 4 things you could hear with severe stenosis?
Whooshing crescendo-decrescendo murmur
Ejection click
Soft S2
S4
What would you see on CXR for aortic stenosis?
LV prominence
What would you see on cardiac cath to determine aortic stenosis?
Pressure gradient between LV & aorta
Which pts get antibiotic prophylaxis? (pre-dental work)
Prosthetic valves
Previous endocarditis
Congenital heart disease
What is the pressure gradient and aortic valve area that indicates surgery?
Gradient > 50 mmHg
Valve area
What are the advantages/disadvantages to mechanical valves for replacement?
Adv = long lasting Disadv = anti-coag forever
What are the adv/disadv to tissue valves for replacement?
Adv = no coag needed Disadv = degenerates
Which kind of aortic valve disease is associated with complications like aortic dilation, aneurysms and dissection?
Bicuspid AV valves
What could be the reason bicuspid valve is also seen with aortic disease?
Fibrillin 1 deficiency - smooth muscle cell detach, cell death, loss of structure and elasticity
2 causes of aortic regurgitation
Aortic valve abnormalities
Aortic root abnormalities - if this is the cause, operate immediately!
Pathophys of aortic regurgitation
Aortic valve isn’t strong (opposite of stenosis)
Can’t hold the pressure gradient between aorta and LV
Leaking - pressure and volume in aorta leaks back into LV = ↑SV
How does PP change with chronic aortic regurg?
PP wider b/c = ↓DP + ↑SP
How does the structure of the LV change with chronic aortic regurg?
LV too much volume
LV dilation
↑LV EDV –> ↑wall stress –> new sarcomers form
Describe LV hypertrophy in aortic regurg vs stenosis
Regurg = eccentric LVH (volume overload)
- Hypertrophy + dilated cavity
Stenosis = concentric (P overload)
What is the net result of chronic aortic regurg?
CHF rEF + ↑diastolic pressure
How are sarcomeres laid down in stenosis vs regurg
Stenosis = in parallel = concentric hypertrophy Regurg = in series = dilation + eccentric hypertrophy
What does aortic regurg murmur sound like?
Blowing after S2
Longer the murmer the more severe the regurg
Hear 2 beats then whoosh
Vs. 1 beat whoosh beat 2 = stenosis
Is aortic stenosis a systolic or diastolic murmur?
Systolic cres-decres
Is aortic regurg a systolic or diastolic murmur?
Diastolic decres
What is a clinical sign of high PP?
Head bob
What do you see on doppler/echo for stenosis vs regurg?
Stenosis = see calcification/valve changes
Regurg - see the blood moving in opposite direction
Major differences between acute and chronic aortic regurg - include cardiomegaly and PP
Acute = still, small LV, ↑diastolic pressure, surg emergency b/c massive pulm edema - NO cardiomegaly - NO wide PP - NO long blowing murmur Chronic = LV large, ↓DP ventricle
What are key signs to make you think acute aortic regurg
Acute endocarditis
Aortic dissection
What 2 drug classes do you want to use for aortic regurg
Diuretics - keep volume low
Lower afterload
