Aortic StenosisAortic Stenosis

Bernardo D. Morantte Jr. M.D.Bernardo D. Morantte Jr. M.D.Dept. of MedicineDept. of Medicine

College of MedicineCollege of MedicinePamantasan Ng Lungsod Ng MaynilaPamantasan Ng Lungsod Ng Maynila

Aortic stenosisAortic stenosis

It is the narrowing of the aortic valve orifice It is the narrowing of the aortic valve orifice which causes an obstruction to the flow of which causes an obstruction to the flow of blood from the left ventricle (LV) to the blood from the left ventricle (LV) to the aorta (Ao).aorta (Ao).

Left Heart in aortic stenosisLeft Heart in aortic stenosis

EKG EKG

LALA

Aorta Aorta

Mitral valveMitral valve

Aortic valve LVAortic valve LV

Aortic StenosisAortic Stenosis 22

11

22

VA = 2cmVA = 2cm22

VA =4 cmVA =4 cm22

Etiology of Aortic stenosisEtiology of Aortic stenosis

1.1. Congenital Congenital

Valvular _ bicuspid aortic valve (common)Valvular _ bicuspid aortic valve (common)

SubvalvularSubvalvular

SupravalvularSupravalvular

2.2. DegenerativeDegenerative

3.3. Rheumatic feverRheumatic fever

4.4. Connective tissue disease or collagen vascular Connective tissue disease or collagen vascular disease _ SLEdisease _ SLE

PathophysiologyPathophysiology

Normal aortic valve area is 2 cmNormal aortic valve area is 2 cm22

The wear and tear effect causes the valve leaftlets The wear and tear effect causes the valve leaftlets to become rigid and calcifiedto become rigid and calcified

As the valve orifice narrows, the pressure in the As the valve orifice narrows, the pressure in the LV rises and a pressure gradient occurs between LV rises and a pressure gradient occurs between the LV and the aorta.the LV and the aorta.

A pressure gradient is the difference in the A pressure gradient is the difference in the pressure (mm Hg) inside the LV and the aorta pressure (mm Hg) inside the LV and the aorta

PATHOPHYSIOLOGYPATHOPHYSIOLOGY LV pressure LA pressure CHFLV pressure LA pressure CHF

LVH LA dilatation &LVH LA dilatation & hypertrophy hypertrophy PulmonaryPulmonary Reduced CO hypertensionReduced CO hypertension

Pulmonic regurgPulmonic regurg HypotensionHypotension RV dilatationRV dilatation Tricuspid regurgTricuspid regurg

Symptoms of ASSymptoms of AS

Mild to moderate aortic stenosis are Mild to moderate aortic stenosis are usually asymptomaticusually asymptomatic

Angina like chest painAngina like chest pain EasifatigabilityEasifatigability Dyspnea/ orthopnea/ PNDDyspnea/ orthopnea/ PND Exertional SyncopeExertional Syncope

Physical ExamPhysical Exam

Pulsus tardus in the carotid arteryPulsus tardus in the carotid artery Thrill and harsh crescendo-decrescendo Thrill and harsh crescendo-decrescendo

systolic murmur at the 2systolic murmur at the 2ndnd RICS RICS Early systolic click is present if valve is still Early systolic click is present if valve is still

pliablepliable Single S2 or paradoxical splitting of S2Single S2 or paradoxical splitting of S2 S4 presentS4 present S3 when LV dilatation and CHF occursS3 when LV dilatation and CHF occurs

Diffferential DiagnosisDiffferential Diagnosis

Hypertrophic obstructive cardiomyopathyHypertrophic obstructive cardiomyopathy Pulmonic stenosisPulmonic stenosis VSDVSD Mitral regurgitationMitral regurgitation Carotid artery stenosisCarotid artery stenosis Benign systolic murmurBenign systolic murmur

The location and quality of the murmur differentiates it from the above conditions.

DiagnosticsDiagnostics

EKG _ LVH, LAHEKG _ LVH, LAH LV strain pattern ( ST depression) LV strain pattern ( ST depression)

CXR_ normal heart sizeCXR_ normal heart size dilated aortadilated aorta LA enlargementLA enlargement enlarge heart ushers the onset of enlarge heart ushers the onset of CHF CHF

EchocardiographyEchocardiography Bicuspid aortic valveBicuspid aortic valve Deformed and calcified aortic valveDeformed and calcified aortic valve Reduced aortic valve openingReduced aortic valve opening Left ventricular hypertrophy and left atrial Left ventricular hypertrophy and left atrial

dilatationdilatation Ejection fraction (EF) usually normal (55 % or >) Ejection fraction (EF) usually normal (55 % or >)

but declines with the onset of CHFbut declines with the onset of CHFOn DopplerOn Doppler Increased velocity at the aortic valveIncreased velocity at the aortic valve usually 4 m/ sec or >usually 4 m/ sec or >

Gradient = 4 V square

Ejection FractionEjection Fraction EF = EDV - ESV %EF = EDV - ESV %

Cross sectional view of Left ventricle (LV)Cross sectional view of Left ventricle (LV)

End diastolic volume (EDV) End systolic volume (ESV) End diastolic volume (EDV) End systolic volume (ESV)

Cardiac CatheterizationCardiac Catheterization

Clinically significant AS _presence of Clinically significant AS _presence of pressure gradient of 50 mm Hg or higher pressure gradient of 50 mm Hg or higher at rest in a patient with normal cardiac at rest in a patient with normal cardiac outputoutput

Severe aortic stenosis = Aortic valve area Severe aortic stenosis = Aortic valve area of < 1 cmof < 1 cm22 or < 0.75 cm or < 0.75 cm22/m/m22

ComplicationsComplications

EndocarditisEndocarditis Congestive Heart FailureCongestive Heart Failure Cardiac arrhythmiaCardiac arrhythmia Sudden deathSudden death

Natural History of Aortic Stenosis Natural History of Aortic Stenosis from onset of symptomsfrom onset of symptoms

DeathDeath Angina pectoris 3 yearsAngina pectoris 3 years Syncope 3 yearsSyncope 3 years Dyspnea 2 yearsDyspnea 2 years CHF 1.5 -2 yearsCHF 1.5 -2 years

Medical ManagementMedical Management Restriction of sports and strenuous physical activityRestriction of sports and strenuous physical activity Importance of fluids or hydration in the absence of CHFImportance of fluids or hydration in the absence of CHF Treatment of Cardiac arrhythmiasTreatment of Cardiac arrhythmias Cautious use of NTG for anginaCautious use of NTG for angina Ace Inhibitors have unproven long term benefits_ risk of syncope!Ace Inhibitors have unproven long term benefits_ risk of syncope! SBE prophylaxisSBE prophylaxis

Balloon valvuloplasty for severe aortic stenosis with pliable leaflets Balloon valvuloplasty for severe aortic stenosis with pliable leaflets especially in children and young adultsespecially in children and young adults

DON’TSDON’TS Digitalis is contraindicated except for control of SVT or A-fibDigitalis is contraindicated except for control of SVT or A-fib Treadmill exercise test is contraindicated in severe aortic stenosisTreadmill exercise test is contraindicated in severe aortic stenosis

Indications for intervention or Indications for intervention or surgerysurgery

Presence of symptoms assuming that Presence of symptoms assuming that there are no other explanation for the there are no other explanation for the symptomssymptoms

Aortic valve area of < 1 cmAortic valve area of < 1 cm22 or less or less

Surgical TherapySurgical Therapy

Aortic valve replacement for valvular aortic stenosis Aortic valve replacement for valvular aortic stenosis with:with:

BioprosthesisBioprosthesis Mechanical valvesMechanical valves

Open incision or excision for subvalvular or Open incision or excision for subvalvular or supravalvular aortic stenosissupravalvular aortic stenosis

Surgical mortality 8%Surgical mortality 8% For patients with reduced EF or CHF, surgical For patients with reduced EF or CHF, surgical

mortality is 20 %mortality is 20 %

Survival rate after AVRSurvival rate after AVR

60 % 10 year survival60 % 10 year survival With bioprosthesis 30% requires repeat With bioprosthesis 30% requires repeat

valve replacement after 8-10 years valve replacement after 8-10 years

END of Aortic StenosisEND of Aortic Stenosis

Aortic regurgitation (AR)Aortic regurgitation (AR)

It is the backward flow of blood from the It is the backward flow of blood from the aorta to the left ventricle (LV) in diastoleaorta to the left ventricle (LV) in diastole

It is also known as aortic insufficiency (AI)It is also known as aortic insufficiency (AI)

Left Heart _ Aortic regurgitationLeft Heart _ Aortic regurgitation

EKG EKG

LALA

Aorta Mitral valveAorta Mitral valve

Aortic valve LV Aortic valve LV

22

VA = 2cmVA = 2cm22

VA =4 cmVA =4 cm22

PathophysiologyPathophysiology

Left ventricular volume = Regurgitant Left ventricular volume = Regurgitant volume from the aorta + forward volume volume from the aorta + forward volume from the left atriumfrom the left atrium

Pathophysiology of ARPathophysiology of AR

LV volume LV volume

LA dilatationLA dilatation LV dilatationLV dilatation LA pressure LA pressure LV stroke volume LV stroke volume CHFCHF Aortic dilatationAortic dilatation

Etiology of aortic regurgitationEtiology of aortic regurgitation

AcuteAcute Acute / subacute Acute / subacute

endocarditisendocarditis TraumaTrauma Aortic dissection /Aortic dissection /

Marfan’s syndromeMarfan’s syndrome

ChronicChronic CongenitalCongenital Rheumatic heart Rheumatic heart

diseasedisease Connective tissue Connective tissue

disease such as disease such as Rheumatoid arthritis Rheumatoid arthritis ankylosing spondylitisankylosing spondylitis

Lupus ErythematosusLupus Erythematosus SyphilisSyphilis

SymptomsSymptoms

EarlyEarly AsymptomaticAsymptomatic Awareness of heart Awareness of heart

beats or palpitationbeats or palpitation

LateLate EasifatigabilityEasifatigability Exertional dyspneaExertional dyspnea Orthopnea / PNDOrthopnea / PND EdemaEdema Chest painsChest pains

Physical examinationPhysical examination Systolic hypertensionSystolic hypertension Wide pulse pressureWide pulse pressure Besferiens and waterhammer pulse (Corrigan’s)Besferiens and waterhammer pulse (Corrigan’s) Hyperdynamic precordium and apical impulse is displaced to the left and Hyperdynamic precordium and apical impulse is displaced to the left and

inferiorlyinferiorly Thrill and a diastolic blowing murmur at the 3Thrill and a diastolic blowing murmur at the 3rdrd LICS or 2 LICS or 2ndnd RICS RICS S3S3 Plus the findings below in moderately severe to severe AR Plus the findings below in moderately severe to severe AR Head bobbingHead bobbing suprasternal notch pulsation (aortic dilatation)suprasternal notch pulsation (aortic dilatation) Diastolic murmur at the apex ( Austin flint murmur)Diastolic murmur at the apex ( Austin flint murmur) Pistol shot (Traube sign)Pistol shot (Traube sign) Dorosiez signDorosiez sign Quinke’s pulseQuinke’s pulse Signs of CHFSigns of CHF

Differential DiagnosisDifferential Diagnosis

Pulmonic regurgitationPulmonic regurgitation Coronary sinus AV fistulaCoronary sinus AV fistula Mitral stenosisMitral stenosis Aortic dissectionAortic dissection

DIAGNOSTICSDIAGNOSTICS

EKG _ LVH, LAHEKG _ LVH, LAH LBBBLBBB

Chest x-rayChest x-ray• cardiomegaly with the apex displaced cardiomegaly with the apex displaced downward and to the leftdownward and to the left• Left atrial enlargementLeft atrial enlargement• dilated aortadilated aorta

EchocardiogramEchocardiogram

Deformed aortic leafletsDeformed aortic leaflets Presence of calcification suggest a combined Presence of calcification suggest a combined

AS/ AR lesionAS/ AR lesion Austin Flint phenomena in the mitral valveAustin Flint phenomena in the mitral valve LV and LA dilatationLV and LA dilatation Initially EF is normal or increased Initially EF is normal or increased DopplerDoppler Presence of regurgitant jet flow from aorta to LVPresence of regurgitant jet flow from aorta to LV

Chest CT scan Chest CT scan

To exclude aortic dissection if patient To exclude aortic dissection if patient presents with chest painspresents with chest pains

Markedly dilated aortaMarkedly dilated aorta Following severe chest traumaFollowing severe chest trauma

Cardiac CathCardiac Cath

Aortic root angiographyAortic root angiography

Backflow of x-ray contrast material Backflow of x-ray contrast material

from the aorta to the LVfrom the aorta to the LV

Aortic root angiography is relatively Aortic root angiography is relatively contraindicated in the presence of aortic contraindicated in the presence of aortic dissectiondissection

Other diagnostic studiesOther diagnostic studies

RA factorRA factor ANA titer and LE prep ANA titer and LE prep VDRL and RPRVDRL and RPR Blood cultures for febrile patientsBlood cultures for febrile patients

Medical therapyMedical therapy Fluid and salt restrictionFluid and salt restriction Ace inhibitorsAce inhibitors DigoxinDigoxin DuireticsDuiretics Treat cardiac arrhythmias if present Treat cardiac arrhythmias if present SBE prophylaxis with appropriate antibioticsSBE prophylaxis with appropriate antibiotics Depending on the history, PE and results of diagnostic test:Depending on the history, PE and results of diagnostic test: Rheumatic fever prophylaxisRheumatic fever prophylaxis Antibiotic therapy for endocarditisAntibiotic therapy for endocarditis Penicillin therapy for syphilisPenicillin therapy for syphilis Steroid therapy for connective tissue diseaseSteroid therapy for connective tissue disease

Indications for surgery in ARIndications for surgery in AR

Class III-VI functional capacityClass III-VI functional capacity EF< 55 %EF< 55 % LV end systolic volume of 55 ml /mLV end systolic volume of 55 ml /m2 2 or > in or > in

the echocardiogramthe echocardiogram

Surgical therapySurgical therapy

Aortic valve replacement Aortic valve replacement

BioprosthesisBioprosthesis

Mechanical valveMechanical valve

ENDEND