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    Aortic Stenosis

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    dr.moni.co.uk
    This document discusses aortic stenosis, including its causes, pathophysiology, symptoms, signs, investigations, and treatment options. It notes that aortic stenosis is commonly caused by rheumatic heart disease, congenital bicuspid aortic valves, or calcific degeneration. The pathophysiology involves pressure overload on the left ventricle leading to hypertrophy, diastolic dysfunction, and outflow obstruction. Common symptoms include angina, exertional dyspnea, and syncope. Investigations include echocardiography, CT, and MRI. Treatment involves surgical aortic valve replacement for symptomatic patients or those with progressive disease, while conservative management is appropriate for asymptomatic cases with regular follow-up.

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    Aortic Stenosis

    Uploaded by

    dr.moni.co.uk
    50 views8 pages
    This document discusses aortic stenosis, including its causes, pathophysiology, symptoms, signs, investigations, and treatment options. It notes that aortic stenosis is commonly caused by rheumatic heart disease, congenital bicuspid aortic valves, or calcific degeneration. The pathophysiology involves pressure overload on the left ventricle leading to hypertrophy, diastolic dysfunction, and outflow obstruction. Common symptoms include angina, exertional dyspnea, and syncope. Investigations include echocardiography, CT, and MRI. Treatment involves surgical aortic valve replacement for symptomatic patients or those with progressive disease, while conservative management is appropriate for asymptomatic cases with regular follow-up.

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    This document discusses aortic stenosis, including its causes, pathophysiology, symptoms, signs, investigations, and treatment options. It notes that aortic stenosis is commonly caused by rheumatic heart disease, congenital bicuspid aortic valves, or calcific degeneration. The pathophysiology involves pressure overload on the left ventricle leading to hypertrophy, diastolic dysfunction, and outflow obstruction. Common symptoms include angina, exertional dyspnea, and syncope. Investigations include echocardiography, CT, and MRI. Treatment involves surgical aortic valve replacement for symptomatic patients or those with progressive disease, while conservative management is appropriate for asymptomatic cases with regular follow-up.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    50 views8 pages

    Aortic Stenosis

    Uploaded by

    dr.moni.co.uk
    This document discusses aortic stenosis, including its causes, pathophysiology, symptoms, signs, investigations, and treatment options. It notes that aortic stenosis is commonly caused by rheumatic heart disease, congenital bicuspid aortic valves, or calcific degeneration. The pathophysiology involves pressure overload on the left ventricle leading to hypertrophy, diastolic dysfunction, and outflow obstruction. Common symptoms include angina, exertional dyspnea, and syncope. Investigations include echocardiography, CT, and MRI. Treatment involves surgical aortic valve replacement for symptomatic patients or those with progressive disease, while conservative management is appropriate for asymptomatic cases with regular follow-up.

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    of 8

    Bismillahir Rahmanir Raheem

    Aortic stenosis
    Ref: Davisson’s Principles and Practice of Medicine,24th e
    Kumar & Clark’s Clinical Medicine, 9th e

    To follow our free lectures on YouTube ,


    Channel name:
    Muhammad Mosleh Uddin

    Muhammad Mosleh Uddin

    MBBS, 59th Batch

    Chattogram Medical College

    Dedicated to my beloved Abbu & Ammu


    Bismillahir Rahmanir Raheem
    Causes :
    Note: In rheumatic heart disease, the
    Infants ,Children,Adolescent
    aortic valve is affected in about 30–
    aortic stenosis of congenital bicuspid aortic valve
    40% of cases and there is usually
    Young adult - Middle aged associated mitral valve disease.
    Rheumatic aortic stenosis
    Calcification & Fibrosis of congenital bicuspid aortic valve Congenital bicuspid aortic
    Middle aged - Elderly valve is associated with

    Senile degenerative coarctation, root dilatation


    and, potentially, aortic
    Rheumatic aortic stenosis
    dissection, and patients
    Calcification &Fibrosis of congenital bicuspid aortic valve should have regular follow-up
    Calcific Aortic Valvular Disease (CAVD) echocardiography.
    Risk factors :
    1. old age 2. male gender 3. elevated lipoprotein
    pathophusiology: 4. LDL. 5. hypertension. 6. diabetes 7. smoking.

    Initially LV can maintain normal CO at resting state—-> Pressure overload on LV —->


    Concentric hypertrophy of LV —-> Diastolic dysfunction (HFpEF) —-> and outflow obstruction
    of LV ——> blood can not come into LV from LA —-> Left atrial pressure rises ——>
    Pulmonary venous congestion and/or pulmonary oedema.

    # Concentric hypertrophy of LV —-> increased demand of oxygen during exertion —-> relative
    O2 lacking —-> Angina.

    Symptoms
    Angina with or without CAD. Angina
    Exertional dyspnea Fatigue (reduced CO)
    Exertional syncope Pre-syncope
    Episodes of acute pulmonary edema
    Sudden death Normal Concentric hypertrophy

    Note: mild and moderate AS doesn’t show any signs and symptoms usually. So most often it is
    diagnosed during Echocardiography. Note: Severe aortic stenosis may not cause symptoms due to
    patient’s sedentary life style.But ETT may reveal ST depression.
    supravalvular obstruction – a congenital fibrous diaphragm above the aortic valve, often
    associated with mental retardation and hypercalcaemia (Williams syndrome)
    • subvalvular aortic stenosis – a congenital condition in which a fibrous ridge or diaphragm is
    situated immediately below the aortic valve.
    • hypertrophic cardiomyopathy – septal muscle hypertrophy obstructing left ventricular outflow.

    Triad of Aortic stenosis :


    1. Exertional dyspnea
    2. Angina
    3. Exertional syncope

    Why does angina occur in AS ?


    In Aortic stenosis —-> pressure overload on LV ——> Concentric hypertrophy of LV
    —-> Oxygen demand increases during exertion (as there are now more muscle mass)
    —-> but oxygen supply remains as it was earlier ——> that’s why there occurs relative
    ischemia to heart during exertion —-> Angina.

    Why does exertional syncope occur in AS ?


    On exertion -—-> Sympathetic output increases on SA node -—-> Heart rate increases
    —-> LV gets far less time (diastole) to be filled with blood from LA -—-> So, LV can not
    be fulfilled adequately with blood from LA (moreover there is outflow obstruction in LV) —-> so
    stroke volume of LV decreases. As LV gets little amount of blood from LA and also can
    not pump out the blood due to outflow obstruction —-> so, CO decreases ——>so,
    systolic BP decreases ——> Cerebral hypo-perfusion ——> exertional syncope.
    Why does exertional duspnea occur in AS ?

    On exertion, venous return increases —-> more blood come into RA —-> more blood come
    into RV —-> more blood come into pulmonary capillary bed ——> more blood come into left
    atrium —-> more blood come into left ventricle —-> But these excess amount blood can not
    go out adequately from left ventricle due to outflow obstruction (AS) ——> So in next
    cardiac cycle, blood can not come adequately into LV from LA —-> Pressure suddenly
    increases more in LA ——> so blood can not come adequately into LA from pulmonary
    circulation —-> blood is accumulated within pulmonary circulation—-> pulmonary venous
    congestion ——> exertional dyspnea.
    Signs of aortic stenosis

    & low volume

    not displaced and sustained


    Systolic thrill at aortic area.
    Sound : ejection click, soft A2
    Murmur :Low pitched, ejection systolic, radiating to carotid region.

    Intentionally left blank


    investigations for Aortic stenosis

    CXR:
    relatively small heart with a prominent,
    dilated ascending aorta. (Kumar&clark)

    # CT
    to see calcification of aortic valve
    # MRI
    to see degree of stenosis

    Planar ST depression & Down sloping ST


    depression indicates ischemia.

    Note: Up- sloping ST depression may be


    normal findings
    Note:
    This ST depression and T inversion indicates ischemia.
    This ischemia occurs due to increased oxygen demand due to
    concentric hypertrophy of LV.

    Post stenotic dilatation of ascending aorta in CXR:


    Due to turbulent blood flow above the stenosed aortic
    valve produces so- called ‘post-stenotic dilatation’. The
    RV hypertrophy with down-sloping ST aortic valve may be calcified. The cardiothoracic ratio
    depression and T inversion
    increases when heart failure occurs.
    The pathology is found at leads I, AVL, V5 and V6)
    Surgical treatment

    #All symptomatic patients should have aortic valve replacement.


    # Patients with a BAV and ascending aorta >50 mm or expanding at >5 mm/year should be considered
    for surgical intervention.
    # Surgical intervention for asymptomatic people with severe aortic stenosis :
    • symptoms during an exercise test or with a drop in blood pressure
    • an LVEF of <50%
    • moderate to severe stenosis undergoing CABG, surgery of the ascending aorta or other cardiac valve.
    Note:
    Delay in surgery may cause sudden death of the patient or irreversible deterioration of left
    ventricular function.
    # Aortic valve replacement

    # Balloon dilatation (valvuloplasty)


    has been tried in adults, especially in the elderly, as an alternative to surgery. Generally results are poor
    and such treatment is reserved for patients unfit for surgery
    # Valvotomy :
    Provided that the valve is not severely deformed or heavily calcified, critical aortic stenosis in
    childhood or adolescence can be treated by valvotomy (performed under direct vision by the surgeon
    or by balloon dilatation using X-ray visualization). This produces temporary relief from the obstruction.
    Aortic valve replacement will usually be needed a few years later.
    # Percutaneous valve replacement
    A novel treatment for patients unsuitable for surgical aortic valve replacement is transcatheter
    implantation with a balloon expandable stent valve. Valve implantation has been shown to be successful
    (86%) with a procedural mortality of 2% and 30-day mortality of 12%.

    Conservative treatment

    # Irrespective of the severity of stenosis, asymptomatic aortic stenosis have good prognosis. And
    conservative management is appropriate.
    # Asymptomatic patients should be under regular review for assessment of symptoms
    (angina,syncope,symptoms of low cardiac output (fatigue), symptoms of heart failure). Because these
    symptoms are indication of surgery.
    # Asymptomatic patients with moderate or severe stenosis should be evaluated every 1-2 yearly
    (every 3-6 monthly for older patient with heavily calcified valve) with Doppler echo to detect
    progression in severity. So that we can take decision for surgery as early as possible.
    O ALLAH subahanahu Oa Tayalaa

    fulfill my heart with your love and niyamah

    Muhammad Mosleh Uddin

    MBBS,59th Batch

    Chattogram Medical College

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