Valvular Heart Disease
Aortic Stenosis
Aortic Regurgitation
Valvular Heart Disease
Essential questions in the pts evaluation :
Is there VHD and how severe is VHD?
What is the aetiology of VHD?
Does the pts has symptoms?
Are any signs present in asymptomatic pts that indicate a worse outcome
if intervention is delayed?
What are the pts life expectancy and expected quality of life?
Do the expected benefits of intervention outweigh its risk?
What is the optimal treatment modality? Surgical valve replacement
(mechanical or biological), surgical valve repair, or catheter intervention?
Are local resources optimal for the planned intervention?
What are the pts wishes?
AORTIC STENOSIS
AS is the most common primary valve
disease leading to surgery or catheter
intervention in Western countries with a
growing prevalence due to aging
population
The most common aetiology is
atherosclerosis (so-called degenerative
AS)
Pathophysiology
Obstructed left ventricular emptying
Increased left ventricular pressure
Left ventricular hypertrophy
Ischaemia of the left ventricular
myocardium,
and consequent angina, arrhythmias
and left ventricular failure
Symptoms
There are usually no symptoms until aortic
stenosis is moderately severe (when the aortic
orifice is reduced to one-third of its normal size -
2-3 sm2).
exercise-induced syncope,
angina
dyspnoea
When symptoms occur, the prognosis is poor -
on average, death occurs within 2-3 years if
there has been no surgical intervention.
Signs
Pulse
The carotid pulse is of small volume and is slow-
rising or plateau in nature.
Precordial palpation
The apex beat is not usually displaced because
hypertrophy (as opposed to dilatation) does not
produce noticeable cardiomegaly.
However, the pulsation is sustained and
obvious.
A double impulse is sometimes felt because the
fourth heart sound or atrial contraction ('kick')
may be palpable.
A systolic thrill may be felt in the aortic area.
Auscultation
An ejection systolic murmur that is usually 'diamond-
shaped'.
The murmur is usually rough in quality and best heard in
the aortic area.
It radiates into the carotid arteries and also the
precordium.
In severe cases, the murmur may be inaudible.
Other findings
a systolic ejection click, unless the valve has become
immobile and calcified.
a soft or inaudible aortic second heart sound when the
aortic valve becomes immobile.
reversed splitting of the second heart sound (splitting on
expiration).
a prominent fourth heart sound, unless coexisting mitral
stenosis prevents this.
Investigations
Chest X-ray
A relatively small heart with a prominent, dilated,
ascending aorta ('post-stenotic dilatation').
The aortic valve may be calcified.
When heart failure occurs, the CTR increases.
Electrocardiogram
left ventricular hypertrophy
left atrial delay.
a left ventricular 'strain' pattern due to 'pressure
overload' (depressed ST segments and T wave inversion
in leads orientated towards the left ventricle, i.e. leads I,
AVL, V5 and V6) is common when the disease is severe.
sinus rhythm is present, but ventricular arrhythmias may
be recorded.
Echocardiogram
thickened, calcified and immobile aortic
valve cusps.
left ventricular hypertrophy (LVESD)
The gradient across the valve can be
estimated by CW Doppler (perivalvular
gradient)
AVA – aortic valve area (mm2)
Svi – stroke volume index
LVOT – LV outflow tract obstruction
Cardiac catheterization and
calcium score
Cardiac catheterization can be used to:
document the systolic pressure difference
(gradient) between the aorta and the left
ventricle
assess left ventricular function.
Coronary angiography is necessary before
recommending surgery.
Calcium score by MSCT: sever AS very likely if
>3000 in men, >1600 in women
Unlikely < 1600 in men, < 800 in women
Treatment
Asymptomatic patients should be under regular review
for assessment of symptoms and echocardiography.
Antibiotic prophylaxis against infective endocarditis is
essential.
Aortic valve replacement: open surgery or TAVI
(transcateter aortic valve implantation)
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.
Balloon dilatation (valvuloplasty) has been tried in adults,
especially in the elderly, as an alternative to surgery.
AORTIC REGURGITATION
AR can be caused by primary disease of
aortic valve cusps and/or abnormalities of
the aortic root and ascending aortic
geometry.
Degenerative tricuspid and bicuspid AR
are the most common aetiologies in
Western countries.
Other causes include infective
endocarditis and rheumatic fever
Pathophysiology
Aortic regurgitation is reflux of blood from the aorta
through
the aortic valve into the left ventricle during diastole.
Net cardiac output is maintained
The total volume of blood pumped into the aorta increase
The left ventricular size enlarge
The demand for oxygen is greater
Cardiac ischaemia develops
Coronary perfusion is decreased
Diastolic blood pressure falls
The aortic run-off during diastole
Symptoms
Symptoms occur late and do not develop
until left ventricular failure occurs.
'Pounding of the heart' because of the
increased left ventricular size and its
vigorous pulsation.
Angina pectoris is a frequent complaint.
Varying grades of dyspnoea occur
depending on the extent of left ventricular
dilatation and dysfunction.
Syncope due to decreased cardiac output
Arrhythmias are relatively uncommon.
Signs
The signs of aortic regurgitation are
many and are due to:
the hyperdynamic circulation
(apparent head pulsation, capillary pulses, visible
carotid arteries pulsation)
reflux of blood into the left ventricle
(high SBP, low DBP, high pulse BP)
the increased left ventricular size.
Auscultation
a high-pitched early diastolic murmur best
heard at the left sternal edge in the fourth
intercostal space with the patient leaning
forward and the breath held in expiration.
an ejection systolic flow murmur (because
of the volume overload).
The regurgitant jet can impinge on the
anterior mitral valve cusp, causing a mid-
diastolic murmur (Austin Flint).
Investigations
Chest X-ray
left ventricular enlargement
dilatation of the ascending aorta (possibly)
the ascending aortic wall may be calcified
in syphilis
the aortic valve may be calcified if valvular
disease is responsible for the
regurgitation.
Electrocardiogram
left ventricular hypertrophy due to 'volume
overload' - tall R waves and deeply
inverted T waves in the left-sided chest
leads, and deep S waves in the right-sided
leads.
Normally, sinus rhythm is present.
Echocardiogram
Vigorous cardiac contraction
Enlarged left ventricle (LVEDD, LVESD –end-
diastolic and systolic diameter)
The aortic root may also be enlarged
Diastolic fluttering of the mitral leaflets or septum
occurs in severe aortic regurgitation (producing
the Austin Flint murmur).
The regurgitant jet can be detected by CW
Doppler.
EROA - effective regurgitant orifice area > 30
Regurgitant volume >60 ml
Cardiac catheterization
During cardiac catheterization, injection of
contrast medium into the aorta
(aortography) will outline aortic valvular
abnormalities and allow assessment of the
degree of regurgitation
Angiography in pts with CAD is indicated
before surgery
Treatment
The underlying cause of aortic regurgitation (e.g.
syphilitic aortitis or infective endocarditis) may require
specific treatment.
The treatment of aortic regurgitation usually requires
aortic valve replacement but the timing of surgery is
critical.
Operation is performed before significant symptoms
occur.
The timing of the operation is best determined according
to haemodynamic, echocardiographic or angiographic
criteria.
Both mechanical prostheses and tissue valves are used.
Tissue valves are preferred in the elderly and when
anticoagulants must be avoided, but are contraindicated
in children and young adults because of the rapid
calcification and degeneration of the valves.
Antibiotic prophylaxis against infective endocarditis is
necessary even if a prosthetic valve replacement has
been performed
Indications for surgery in AR
and aortic root disease
Symptomatic pts
Asymptomatic pts with resting LVEF<50% (considered
in pts with LVEF >50% if sever LV dilation)
In pts undergoing CABG or surgery of ascending aorta
or of another valve
In young pts with aortic root dilation
In pts with Marfan syndrome if max aortal diameter >
50 mm or in the presence of a bicuspid valve or
coarctation of aorta
In all pts with ascending aorta dilation > 55 mm
