Valvular Heart Disease
Aortic Stenosis
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...bridging the care gap
Aortic Stenosis
Etiology Physical Examination Assessing Severity Natural History Prognosis Timing of Surgery
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Common Clinical Scenarios
Younger people
Functional murmur vs MVP vs bicuspid AV
Older people
Aortic sclerosis vs aortic stenosis
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Innocent Murmurs
Common in asymptomatic adults Characterized by
Grade I II @ LSB Systolic ejection pattern
S1 S2 Normal intensity & splitting of second sound (S2) No other abnormal sounds or murmurs No evidence of LVH, and no with Valsalva
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An 83 year old man with exertional dyspnea
Previously well Gradual onset Class 2/4 dyspnea Occasional lightheadedness with exertion O/E: 2/6 ejection murmur
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An 83 year old man with exertional dyspnea
Is there significant valvular heart disease? Which valve? Is the valve playing a role in his dyspnea? How do you distinguish AV sclerosis from stenosis? What are the clinical signs of severe AS? What tests are appropriate? When is surgery indicated?
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Aortic Stenosis: Symptoms
Cardinal Symptoms
Chest pain (angina)
Reduced coronary flow reserve Increased demand-high afterload
Syncope/Dizziness (exertional pre-syncope)
Fixed cardiac output Vasodepressor response
Dyspnea on exertion & rest Impaired exercise tolerance
Other signs of LV failure
Diastolic & systolic dysfunction
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Common Murmurs and Timing (click on murmur to play)
Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis
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S1
...bridging the care gap S2
S1
Aortic Stenosis: Physical Findings
S1
S2
S1
Severe
S2
Mild-Moderate
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Aortic Stenosis: Physical Findings
Intensity DOES NOT predict severity Presence of thrill DOES NOT predict severity Diamond shaped, harsh, systolic crescendodecrescendo Decreased, delay & prolongation of pulse amplitude Paradoxical S2 S4 (with left ventricular hypertrophy) S3 (with left ventricular failure)
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Recognizing Aortic Stenosis
Sign JVP-prominent A wave Carotid-delayed, anacrotic A2 audible over carotids Apex- sustained, atrial kick -enlarged, displaced Thrill Cardiomegaly- Clinical/CXR Soft S1 Paradoxical S2 S3, S4 SEM- intensity - late peak ECG- LAE, LVH Correlation with Severity No Yes If A2 transmitted to carotids mean AV gradient 50 mm Hg and stenosis not severe Yes Yes No Yes Yes Yes Yes No Yes Yes
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An 83 year old man with exertional dyspnea
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Aortic Stenosis - Etiology
Young patient think congenital
Bicuspid 2% population 3:1 male:female distribution Co-existing coarctation 6% of patients
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Rarely
Unicuspid valve Sub-aortic stenosis
Discrete Diffuse (Tunnel)
Middle aged patient(4&5th decades) think bicuspid or rheumatic disease Old patient think degenerative (6,7,8th decades)
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Aortic Stenosis: Etiology
Congenital bicuspid valve is the most common abnormality Rheumatic heart disease and degeneration with calcification are found as well
Normal
Bicuspid Ao V
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Normal geriatric ...bridging the care valve calcific gap
Bicuspid Aortic Valve
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Etiology of
Aortic Stenosis
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Severity of Stenosis
Normal aortic valve area 2.5-3.5 cm2 Mild stenosis 1.5-2.5 cm2 Moderate stenosis 1.0-1.5 cm2 Severe stenosis < 1.0 cm2 Onset of symptoms
~ 0.9 cm2 with CAD ~ 0.7 cm2 without CAD
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Echocardiogram
Etiology Valve gradient and area LVH Systolic LV function Diastolic LV function LA size Concomitant regional wall motion abnormalities Coarctation associated with bicuspid AV
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Echocardiogram
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Figure 1: Principles of the Use of Doppler Ultrasonography and the Continuity Equation in Estimating Aortic-Valve Area. For blood flow (A1 x V1) to remain constant when it reaches a stenosis (A2), velocity must increase to V2. Doppler examination of the stenosis detects the increase in velocity, which can be used to calculate the aortic-valve gradient or to solve the continuity equation for A2. A denotes area, and V velocity
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Aortic Stenosis: Prognosis
Symptom/Sign
Angina Syncope Congestive Heart Failure
Live expectancy
5 years 2-3 years 1-2 years
Therapy: Valve replacement for severe aortic stenosis
Operative mortality (elderly) ~ 4-24%/Morbidity ~ 3-11%
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Event rate in asymptomatic severe AS ~ 1%/year gap ...bridging the care
Natural History of Aortic Stenosis
Heart failure reduces life expectancy to less than 2 years Angina and syncope reduce life expectancy between 2 and 5 years Rate of progression @ 0.1 cm2/year
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Operative mortality of AVR in the elderly
~ 4-24%/year Risk factors for operative mortality
Functional class Lack of sinus rhythm HTN Pre-existing LV dysfunction Aortic regurgitation Concomitant surgical procedures:CABG/MV surgery Previous bypass Emergency surgery CAD Female gender
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Prosthetic Heart Valves
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Caged-Ball Valve
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Disc Valve
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Bio-prosthetic Valve
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Prosthetic Valves
MECHANICAL
Durable Large orifice High thromboembolic potential Best in Left Side Chronic warfarin therapy
BIO-PROSTHETIC
Not durable Smaller orifice/functional stenosis Low thromboembolic potential Consider in elderly Best in tricuspid position
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Continuing Medical Implementation
