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AORTIC STENOSIS

This document discusses aortic stenosis, including its causes, symptoms, diagnostic studies, prognosis, and treatment options. It begins with an overview and definitions, then describes the main types and risk factors for aortic stenosis. Diagnostic tests like echocardiography are outlined for evaluating the severity of stenosis. The prognosis without treatment is explained. Treatment involves initially managing symptoms, with surgical aortic valve replacement as the definitive treatment for severe symptomatic stenosis. A case study is presented of an elderly woman found to have incidental moderate aortic stenosis while being evaluated for anemia.

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AORTIC STENOSIS By, Dr. Muhammad Wajahat Final year, MBBS, DMC.
OVERVIEW • General Considerations • Approach to the patient • Diagnostic Studies • Prognosis • Treatment • Case Study
GENERAL CONSIDERATION
• Normal aortic valve surface area is 03 – 04 cm2 • Narrowing of aortic orifice is called aortic stenosis
Etiology • Congenitally Abnormal Bicuspid Aortic valve • Senile Degenerated or calcified Aortic valve • Rheumatic heart Disease
Bicuspid Aortic valve • Congenital Abnormality • Commonly emerge at the age of 50 to 65 yrs. • Associated with Coarctation of Aorta and Dilated ascending Aorta.
Bicuspid Aortic valve Calcified Bicuspid Aortic valve
Degenerated or calcified Aortic valve • 25% of patients over age 65yrs have echocardiographic evidence of AS • 10 to 20% of them will develop haemodynamically significant Aortic Stenosis • Related with atherosclerotic vascular diseases
Degenerated or calcified Aortic valve
Rheumatic Heart Disease Aortic stenosis is accompanied by Aortic insufficiency and/or mitral valve disease
Aortic Stenosis Mimickers • Subvalvular Stenosis + Hypertrophic Cardiomyopathy + Subvalvular Membrane • Supravalvular Stenosis + William Syndrome (hypercalcemia, growth failure and mental retardation)
Risk Factors • Hyperlipidaemia • Hypertension • Smoking • Family history for bicuspid aortic valve
Pathophysiology
Pathophysiology
APPROACH
• Patients are initial Asymptomatic • Patient becomes symptomatic if: AVA <1.0 cm2 concomitant CAD • Systolic hypertension may coexist but >200mm Hg is uncommon • Hypertrophic Obstructive Cardiomyopathy may also coexist
History • Exertional Angina • Exertional Syncope • Heart Failure • Arrhythmia
Angina • It may occur due to exertion and relieve by rest. • Sometimes, Coronary artery disease may coexist. Syncope • It occurs due to peripheral vasodilatation but unchanged cardiac output • It occurs due to exertion.
Left-sided Heart Failure Symptoms • Exertional Dyspnea • Fatigue • Orthopnea • Paroxysmal Nocturnal Dyspnea • Wheeze (Cardiac Asthma) • Non productive chronic Cough • Exercise intolerance Signs • Tachypnea & tachycardia • Pulsus alternans • Cardiomegaly • Ventricular Gallop (S3) • Basal Crepitations • Pleural Effusion
Physical Examination • Pulse: Plateau Pulse • Narrow pulse pressure • Apex beat may shift to left • Well-sustained heave • A2 component of S2 might be absent/ soft/ normal. • Prominent S4
• Site – Aoric Area (Right 2nd ICS) • Radiation – To neck, through Carotid arteries • Timing – Ejection Sytolic murmur • Character – Harsh • Position – Leaning forward, held in expiration MURMUR
Assessing severity of Aortic Stenosis Clinically Q: Is the severity of stenosis indicated by the intensity of murmer ?? Yes No
NO • It is because the murmur becomes quieter as the Left Ventricle fails and Left ventricular failure becomes apparent.
Severe Stenosis is indicated by • Slow rising pulse • Narrow pulse pressure • Longer duration of murmur • LV heave and S4 ( LVH)
DIAGNOSTIC STUDIES
1) Electrocardiogram
2) Chest X Ray • In Early stage, CXR may be normal or Ascending Aorta dilatation w/ normal heart size • In late Stage, Cardiac enlargement Pulmonary congestion
The ascending aorta (yellow dotted line) leading into the arch is dilated, whereas the distal arch and descending aorta (red dotted line) are normal in size. The left heart border (blue dotted line)
The ascending aorta (yellow dotted line) leading into the arch is dilated, whereas the distal arch and descending aorta (red dotted line) are normal in size.
Calcified aortic valve (green arrows) noted on CT.
3) Two-dimensional Echocargiography w/ Doppler Diagnostic of AS Perform for following purposes: • Evaluate Aortic valve morphology • Calculate Aortic valve area • Evaluate Left Ventricular walls thickness • Calculate Ejection Fraction • Estimate Aortic valve Gradient
Recommendations for Echocardiography in Aortic Stenosis • Diagnosis and assessment of severity of aortic stenosis. • Assessment of LV size, function, and/or hemodynamics • Reevaluation of patients with known aortic stenosis with changing symptoms or signs • Assessment of changes in hemodynamic severity and ventricular function in patients with known aortic stenosis during pregnancy • Reevaluation of asymptomatic patients with severe aortic stenosis • Reevaluation of asymptomatic patients with mild to moderate aortic stenosis and evidence of LV dysfunction or hypertrophy • Routine reevaluation of asymptomatic adult patients with mild aortic stenosis who have stable physical signs and normal LV size and function
Classification of Aortic Stenosis Severity Mean gradient (mm Hg) Aortic valve area (cm2) Mild < 25 >1.5 Moderate 25-40 1-1.5 Severe >40 < 1 (or < 0.5 cm2/m2 body surface area) Critical >80 < 0.5
4) Cardiac Catheterization • Recommended for assessing concomitant CAD • Recommended prior to Aortic valve replacement • If indications for Dobutamine test have been met
5) Emerging Role of BNP • Recognized as a marker of EARLY LV failure • Levels of >550 pg/ml are associated with poor outcomes
PROGNOSIS
• Following the onset of symptoms, prognosis without surgery is poor. 50% 03 yrs mortality rate • Mean survival is based on symptoms: 1. Angina -> 05 yrs 2. Syncope -> 03 yrs 3. Heart failure -> 02yrs • Sudden cardiac death may occur in asymptomatic individuals ~ 04%
TREATMENT
• Depends upon the presenting complaints • If LV failure, Symptom-improving drugs Prognosis-improving drugs • Treating Hypertension, normalizing lipid prolife and smoking cessation has the role. INITIAL TREATMENT
Definitive Treatment • Mechanical solution for mechanical problem AORTIC VALVE REPLACEMENT
AORTIC VALVE REPLACEMENT • There are 2 options for valve replacement in symptomatic patients. • Surgical Valve Replacement • Transcatheter Aortic Valve Replacement (TAVR)
SURGICAL VALVE REPLACEMENT • Mechanical Valve Replacement • Bioprosthetic Valve Replacement
TAVR • It comes second to the Surgical valve replacement • Performed either as a means of temporary stabilization or patients with High Surgical Risk
CASE STUDY
A 70 year old lady, Shamsi Khatoon, resident of Balochistan, with no known co-morbids, presented to ER with the complaints of chest discomfort, blackouts and dizziness on and off for several weeks. She also had a low-grade, continuous fever without any chills or rigors. Her history was negative for breathlessness. Past medical and surgical history was not significant. Systemic review revealed mild heartburn and severe general body weakness.
Physical Examination VITALS • Pulse –84 beats/min (Plateau pulse) • BP – 140/100 mmHg • Temperature – 100 °F • RR- 14 bpm
General Physical Examination • General physical exam revealed pallor consistent with severe anemia • J- A+++ C- K- L- E- D++
Cardiovascular exam • JVP was not raised • Normal Apex Beat • No parasternal heave • Normal S1 • A2 component of S2 was soft • Ejection systolic murmur in leaning forward position and full expiration • No Basal Crepitations on Lung Auscultation
Further Management • ECG • CBC • Urea/Creatinine • RBS • LFTs • Cardiac Markers
Results CBC • Hb - 4.7 mg/dl • Plt – 130000 U&E • BUN - 11 • Creatinine – 0.6 • Chloride – 105 • Potassium – 3.3 • Sodium – 141 LFTs • ALP – 151 • Bilirubin – 0.31 • SGPT – 28 Others • CK-MB – 24 • RBS – 133 mg/dl • ECG was normal
Echocardiography • Thick and calcified Aortic valve • Normal other valves • Ejection fraction - 60% • Mild LV hypertrophy
Treatment Plan • Patient’s hydration status was corrected • Packed RBCs were transfused • The patient’s condition improved rapidly which showed that the symptoms were due to Anemia • The Moderate Aortic stenosis was asymptomatic and incidentally discovered so she was put on Follow-up after 2 weeks
AORTIC STENOSIS