Common Clinical ScenariosCommon Clinical Scenarios

* * Younger peopleYounger people_ _ Functional murmur vsFunctional murmur vs

_ _ MVP vsMVP vs _ _ ASAS

**Older peopleOlder people_ _ Aortic sclerosis Aortic sclerosis

vs _Aortic vs _Aortic stenosisstenosis

AetiologyAetiology

Young patientYoung patient__Thick congenital bicuspidThick congenital bicuspid

valvevalve* * 2%2% populationpopulation

* * 3:13:1 male:femalemale:female * * Co-existing COA 6% Co-existing COA 6%

patientspatients_ _ RarelyRarely

* * Unicuspid valveUnicuspid valve* * supravalvular ASsupravalvular AS

* * Subaortic stenosisSubaortic stenosis_ _ DiscreteDiscrete

_ _ Diffuse { Tunnel}Diffuse { Tunnel}

Middle age {40- 50y }Middle age {40- 50y } __Thick bicuspid valveThick bicuspid valve

_ _ Rheumatic diseaseRheumatic disease

Old age {60- 80y}Old age {60- 80y} _ _ Thick Thick

degenerativedegenerative valvevalve

_ _ Calcification of Calcification of bicuspid valve bicuspid valve

_ _ Rheumatic ASRheumatic AS

Aortic StenosisAortic Stenosis SubvalvularSubvalvular

SupravalvularSupravalvular

ValvularValvular

((HCM; IHSSHCM; IHSS

COP maintained normal for years by progressive LVH _ Coronary blood flow becomes inadequate Exertional

Angina_ LV outflow obstruction limits COP after exercise Exertional

syncope _ LVEDP raise Pulmonary congestion

Dyspnoea ,Pulmonary oedema_ Patients asymptomatic for long time once symptoms appear

deteriorate rapidly

Clinical featuresClinical features::**Cardinal SymptomsCardinal Symptoms

_ _ Mild or moderate AS usually asymptomaticMild or moderate AS usually asymptomatic_ _ Chest pain (anginaChest pain (angina))

Rreduced coronary flow reserveRreduced coronary flow reserve Increased demand-high afterloadIncreased demand-high afterload

_ _ Syncope/Dizziness (exertional pre-syncope)Syncope/Dizziness (exertional pre-syncope) Fixed cardiac outputFixed cardiac output

Vasodepressor responseVasodepressor response_ _ Dyspnoea on exertion & restDyspnoea on exertion & rest

Impaired exercise toleranceImpaired exercise tolerance_ _ Episodes of acute pulmonary oedemaEpisodes of acute pulmonary oedema

_ _ Sudden deathSudden death**Other signs of LV failureOther signs of LV failure

Diastolic & systolic dysfunctionDiastolic & systolic dysfunction

Clinical features cont..

*Signs_ Ejection systolic murmer_ Slaw rising carotid pulse

_ Narrow pulse pressure_ Thrusting apex beat { LV pressure overload }

_ Signs of pulmonary congestion { basal crepitation }

AuscultationAuscultation: :

S1 S2 S1 S2

Mild-Moderate Severe

Some points about physical signsSome points about physical signs: : _ _ Intensity DOES NOT predict severityIntensity DOES NOT predict severity

_ _ Presence of thrill DOES NOT predict severityPresence of thrill DOES NOT predict severity Conditions indicating severityConditions indicating severity::

”_ ”_ Diamond” shaped, harsh, systolic Diamond” shaped, harsh, systolic crescendo- decrescendo {Long crescendo- decrescendo {Long murmer}murmer}

_ _ Decreased, delay & prolongation of pulse Decreased, delay & prolongation of pulse amplitude {Anacrotic pulse } amplitude {Anacrotic pulse }

_ _ Paradoxical S2Paradoxical S2 _ _ S4 (with left ventricular hypertrophy)S4 (with left ventricular hypertrophy)

_ _ S3 (with left ventricular failure)S3 (with left ventricular failure)

* ECG _ LVH _ LBBB _May be normal

* Chest XR _Enlarged LV _Dilated Ascending aorta_ May be normal _Calcified AV

* ECHO _Calcified AV with restricted opening_ Thickened LV walls

* Dopler _ Estimates gradient _detects AR* Cardiac Catheterization:

_ Systolic gradient between LV and Aorta_ Post-stenotic dilatation of aorta

_ Detects AR if present_ To detect presence of CAD

ECGECG

PA LL

Chest X-ray

2-d ECHO LX

Calcified cusps

Subvalvuler

Natural Natural historyhistory

_ _ Heart failure reduces life Heart failure reduces life expectancy to less expectancy to less than 2 yearsthan 2 years

_ _ Angina and syncope reduce Angina and syncope reduce life expectancy between life expectancy between 2 and 5 years2 and 5 years

_ _ Rate of progression Rate of progression @ 0.1 @ 0.1 cm2/year cm2/year

ECHO ECHO (cont.)(cont.)

Criteria for determining severity of Criteria for determining severity of ASAS

G (mmHg)G (mmHg) AVA (cmAVA (cm22))MildMild < <2525 > >1.51.5

ModerateModerate 25-5025-50 1-1.51-1.5

SevereSevere 50-8050-80 0.7-10.7-1

CriticalCritical >>8080 <<0.70.7

* Medical _ Prophylaxis against IE

_ Anticoagulants if in AF_ Diuretics cautiously for pulmonary congestion

_ Vasodilators are CONTRAINDICATED

*Surgical _Patients with symptoms and valve gradient >50 and

normal COP should have AV replacement { Mechanical }

_ Symptomatic Elderly patients need AV replacement with{ Bioprosthesis}

_ Aortic Balloon valvoplasty for congenital AS

Disc ValveDisc ValveBio-prosthetic ValveBio-prosthetic Valve

Caged-Ball ValveCaged-Ball Valve

Comparison between Mechanical and Prosthetic ValvesComparison between Mechanical and Prosthetic Valves

* *MECHANICALMECHANICAL_ _ DurableDurable

_ _ Large orificeLarge orifice

_ _ High thromboembolic High thromboembolic potential potential

_ _ Best in Left SideBest in Left Side_ _ Chronic warfarin Chronic warfarin

therapy therapy

BIO-PROSTHETICBIO-PROSTHETIC_ _ Not durableNot durable

_ _ Smaller Smaller orifice/functional orifice/functional stenosis stenosis

_ _ Low thromboembolic Low thromboembolic potential potential

_ _ Consider in elderlyConsider in elderly_ _ Best in tricuspidBest in tricuspid

positionposition

Common Murmurs and Common Murmurs and Timing Timing (click on murmur to play((click on murmur to play(

Systolic MurmursSystolic MurmursAortic stenosisAortic stenosisMitral insufficiencyMitral insufficiencyMitral valve prolapseMitral valve prolapseTricuspid insufficiencyTricuspid insufficiency Diastolic MurmursDiastolic MurmursAortic insufficiencyAortic insufficiencyMitral stenosisMitral stenosis

S1 S2 S1