Station 3.1: Aortic stenosis

Question 1

Clinical signs

What are the clinical signs of Aortic stenosis?

Aortic stenosis

This patient presents with increasing dyspnoea. Examine his cardiovascular system to elucidate the
cause.

Answer 1

• Slow rising, low volume pulse
• Narrow pulse pressure
• Apex beat is sustained in stenosis (HP: heaving pressure‐loaded)
• Thrill in aortic area (right sternal edge, second intercostal space)
• Auscultation

Question 2

Clinical signs

What are the clinical signs of Aortic stenosis?

Aortic stenosis

This patient presents with increasing dyspnoea. Examine his cardiovascular system to elucidate the
cause.

Answer 2

• Slow rising, low volume pulse
• Narrow pulse pressure
• Apex beat is sustained in stenosis (HP: heaving pressure‐loaded)
• Thrill in aortic area (right sternal edge, second intercostal space)
• Auscultation

Question 3

Discussion - Evidence of complication

What are the Evidence of complications in Aortic stenosis?

Aortic stenosis

This patient presents with increasing dyspnoea. Examine his cardiovascular system to elucidate the
cause.

Answer 3

• Endocarditis: splinters, Osler’s nodes (finger pulp), Janeway lesions (palms), Roth spots (retina), temperature, splenomegaly and haematuria
• Left ventricular dysfunction: dyspnoea, displaced apex and bibasal crackles
• Conduction problems: acute, endocarditis; chronic, calcified aortic valve node

Question 4

Discussion - Differential diagnosis

What is the differential diagnosis for Aortic stenosis?

Aortic stenosis

This patient presents with increasing dyspnoea. Examine his cardiovascular system to elucidate the
cause.

Answer 4

• HOCM
• VSD
• Aortic sclerosis: normal pulse character and no radiation of murmur
• Aortic flow: high output clinical states e.g. pregnancy or anaemia

Question 5

Discussion - Causes of Aortic Stenosis

What are the causes of Aortic stenosis?

Aortic stenosis

This patient presents with increasing dyspnoea. Examine his cardiovascular system to elucidate the
cause.

Answer 5

Congenital: bicuspid
Acquired: Age (senile degeneration and calcification); Streptococcal (rheumatic)

Question 6

Discussion - Associations

What are the associations of Aortic stenosis?

Aortic stenosis

This patient presents with increasing dyspnoea. Examine his cardiovascular system to elucidate the
cause.

Answer 6

• Coarctation and bicuspid aortic valve
• Angiodysplasia

Question 7

Discussion - severity

Whats the aseverity of Aortic stenosis?

Aortic stenosis

This patient presents with increasing dyspnoea. Examine his cardiovascular system to elucidate the
cause.

Answer 7

Symptom ———————— 50% Mortality at
Angina ——————————— 5 years
Syncope ——————————- 3 years
Breathlessness ———————- 2 years

• Signs
  Auscultation features (see figure), biventricular failure (right ventricular failure is preterminal).

Question 8

Discussion - investigations

What investigations are required for Aortic stenosis?

Aortic stenosis

This patient presents with increasing dyspnoea. Examine his cardiovascular system to elucidate the
cause.

Answer 8

• ECG: LVH on voltage criteria, conduction defect (prolonged PR interval)
• CXR: often normal; calcified valve
• Echo: mean gradient: >40mm Hg aortic (valve area <1.0cm2) if severe
• Catheter: invasive transvalvular gradient and coronary angiography (coronary artery disease often coexists with aortic stenosis)

Question 9

Discussion - management

What method of management do you recommend for Aortic stenosis? 1/2

Aortic stenosis

This patient presents with increasing dyspnoea. Examine his cardiovascular system to elucidate the
cause.

Answer 9

* Asymptomatic
⚬ None specific, good dental health
⚬ Regular review: symptoms and echo to assess gradient and LV function
* Symptomatic
⚬ Surgical
⚬ Aortic valve replacement +/− CABG
⚬ Operative mortality 3–5% depending on the patient’s EuroScore (www.euroscore.org/calc.html)
⚬ Percutaneous
⚬ Balloon aortic valvuloplasty (BAV)
⚬ Transcutaneous aortic valve implantation (TAVI)
⚬ Transfemoral (or transapical and transaortic)
⚬ Maybe recommended if high surgical risk (logEuroscore >20%) or inoperable
cases (number needed to treat to prevent death at 1 year = 5)

Question 10

Discussion - management 2/2

What method of management do you recommend for Aortic stenosis? 2/2

Aortic stenosis

This patient presents with increasing dyspnoea. Examine his cardiovascular system to elucidate the
cause.

Answer 10

Duke’s criteria for infective endocarditis
Major:
* Typical organism in two blood cultures
* Echo: abscess, large vegetation, dehiscence*

Minor:
* Pyrexia >38°C
* Echo suggestive
* Predisposed, e.g. prosthetic valve
* Embolic phenomena*
* Vasculitic phenomena (ESR↑, CRP↑)
* Atypical organism on blood culture

Diagnose if the patient has 2 major, 1 major and 2 minor, or 5 minor criteria.
(* plus heart failure/refractory to antibiotics/heart block are indicators for urgent
surgery).

Antibiotic prophylaxis is now limited to those with prosthetic valves, previous
endocarditis, cardiac transplants with valvulopathy and certain types of
congenital heart disease.