Aortic Stenosis

Cardiovascular

Clinicals - History

Fact Explanation
Asymptomatic The patient is asymptomatic until the Aortic Stenosis (AS) is moderately severe. (less than one third of its normal size.) Asymptomatic
The patient is asymptomatic until the Aortic Stenosis (AS) is moderately severe. (less than one third of its normal size.)
Angina To over come the partial obstructed aortic valve the less ventricle hypertrophies and this increases the myocardial oxygen demand. So with exertion the hear rate increases and the duration of the diastole reduces. Myocardial perfusion mainly occurs during the diastole. With exertion angina results. patient complains tightening type retro-sternal chest pain wich radiates to the left arm and neck. , Angina
To over come the partial obstructed aortic valve the less ventricle hypertrophies and this increases the myocardial oxygen demand. So with exertion the hear rate increases and the duration of the diastole reduces. Myocardial perfusion mainly occurs during the diastole. With exertion angina results. patient complains tightening type retro-sternal chest pain wich radiates to the left arm and neck. ,
Recurrent syncope With the reduced valve surface area the cardiac output diminishes which becomes more significant during exertion. So the patient complains of dizziness and might faint. Once the symptoms of angina, syncope, or heart failure develop, average survival reduces dramatically to less than 2 to 3 years. ,
Syncope at rest may be induced by transient ventricular tachycardia, atrial fibrillation, or atrio-ventricular block.
Recurrent syncope
With the reduced valve surface area the cardiac output diminishes which becomes more significant during exertion. So the patient complains of dizziness and might faint. Once the symptoms of angina, syncope, or heart failure develop, average survival reduces dramatically to less than 2 to 3 years. ,
Syncope at rest may be induced by transient ventricular tachycardia, atrial fibrillation, or atrio-ventricular block.
Features of heart failure. Eg: Paroxysmal nocturnal dyspnea, orthopnea, dyspnea on exertion, and shortness of breath. Once the AS is not treated for a long time heart failure develops. Once symptomatic heart failure has developed the average survival is very poor. Features of heart failure. Eg: Paroxysmal nocturnal dyspnea, orthopnea, dyspnea on exertion, and shortness of breath.
Once the AS is not treated for a long time heart failure develops. Once symptomatic heart failure has developed the average survival is very poor.
Triad of chest pain, heart failure and syncope. Aortic stenosis may lead to heart failure and/ or exertional angina and syncope. Triad of chest pain, heart failure and syncope.
Aortic stenosis may lead to heart failure and/ or exertional angina and syncope.
Palpitations Palpitation is the awareness of ones own heart beat. Palpitations
Palpitation is the awareness of ones own heart beat.
History of Rheumatic Fever (RF) This is common in developing countries and occur 5 to 10 years after the RF. By the time the aortic valve is affected the Mitral valve is also affected. History of Rheumatic Fever (RF)
This is common in developing countries and occur 5 to 10 years after the RF. By the time the aortic valve is affected the Mitral valve is also affected.

Clinicals - Examination

Fact Explanation
Small volume slow rising pulse This is due to the obstructed left ventricular output. Small volume slow rising pulse
This is due to the obstructed left ventricular output.
Undisplaced forceful apex beat In order to overcome the AS the left ventricle hypertrophies and this increases the muscle bulk and causes forceful apex. Since there is no volume overload for the ventricles to dilate th eapex is not displaced. Undisplaced forceful apex beat
In order to overcome the AS the left ventricle hypertrophies and this increases the muscle bulk and causes forceful apex. Since there is no volume overload for the ventricles to dilate th eapex is not displaced.
Double impulse of the apex This is a relatively rare finding. Second impulse is due to the forth heart sound (S4) or due to the atrial contraction. Double impulse of the apex
This is a relatively rare finding. Second impulse is due to the forth heart sound (S4) or due to the atrial contraction.
Systolic thrill in the aortic area Due to the turbulent flow across the stenosed aortic valve a thrill is palpable. Systolic thrill in the aortic area
Due to the turbulent flow across the stenosed aortic valve a thrill is palpable.
Ejection systolic murmur The murmur is crescendo- decrescendo in type. (Diamond shape)
Severe the narrowing longer the murmur,but with very severe narrowing the murmur may be inaudible, because the blood flow across the valve is very limited that is is unable to create a turbulent flow and hence the murmur becomes inaudible.
This murmur typically radiates to the carotid arteries.
Once the aortic valve becomes calcified or become immobile the aortic component (A2) of the second heart sound becomes inaudible, otherwise mobile valves produce an ejection systolic click.
Ejection systolic murmur
The murmur is crescendo- decrescendo in type. (Diamond shape)
Severe the narrowing longer the murmur,but with very severe narrowing the murmur may be inaudible, because the blood flow across the valve is very limited that is is unable to create a turbulent flow and hence the murmur becomes inaudible.
This murmur typically radiates to the carotid arteries.
Once the aortic valve becomes calcified or become immobile the aortic component (A2) of the second heart sound becomes inaudible, otherwise mobile valves produce an ejection systolic click.
Reversed splitting of the second heart sound. Once the obstruction is very severe the left ventricle takes longer time to eject blood. This delays the closure of the aortic valve. Reversed splitting of the second heart sound.
Once the obstruction is very severe the left ventricle takes longer time to eject blood. This delays the closure of the aortic valve.

Investigations - Diagnosis

Fact Explanation
Chest X Ray (CXR) Relatively small heart with a prominent dilated ascending aorta. This is due to the post-stenotic dilatation. A calcified aortic valve will also be visible.
Once heart failure develops CXR will show the features of heart failure. Eg: Cardiomegaly, Kerly B lines, Pleural effusions.
Chest X Ray (CXR)
Relatively small heart with a prominent dilated ascending aorta. This is due to the post-stenotic dilatation. A calcified aortic valve will also be visible.
Once heart failure develops CXR will show the features of heart failure. Eg: Cardiomegaly, Kerly B lines, Pleural effusions.
Electrocardiogram (ECG) In severe disease left ventricular hypertrophy will be seen and left ventricular strain pattern occurs due to pressure overload (ST segment depression and T wave inversion of left ventricular leads: Lead I, aVL, V5 and V6). Electrocardiogram (ECG)
In severe disease left ventricular hypertrophy will be seen and left ventricular strain pattern occurs due to pressure overload (ST segment depression and T wave inversion of left ventricular leads: Lead I, aVL, V5 and V6).
2D Echo cardiogram Thickened, calcified and immobile aortic valve cusps will be seen. Left ventricular wall hypertrophy can be demonstrated. The pressure gradient across the valve and the valve surface area can be determined. 2D Echo cardiogram
Thickened, calcified and immobile aortic valve cusps will be seen. Left ventricular wall hypertrophy can be demonstrated. The pressure gradient across the valve and the valve surface area can be determined.
Cardiac catheterisation This is rarely necessary since 2D echo can give the same details which is non invasive. Cardiac catheterisation
This is rarely necessary since 2D echo can give the same details which is non invasive.

Investigations - Management

Fact Explanation
2D Echo cardiogram This is done in the post operative period to ensure the surgical correction.
Patients who have mild AS yearly physical examination and echo in every 5 years should be done. Moderate AS patients should undergo an echo once in two years. Severe AS should be examined twice yearly and whenever they have symptoms. Symptomatic patients should be followed up yearly.
2D Echo cardiogram
This is done in the post operative period to ensure the surgical correction.
Patients who have mild AS yearly physical examination and echo in every 5 years should be done. Moderate AS patients should undergo an echo once in two years. Severe AS should be examined twice yearly and whenever they have symptoms. Symptomatic patients should be followed up yearly.
Full blood count Low hemoglobin levels will aggravate heart failure and angina on exertion. So it should be corrected. Full blood count
Low hemoglobin levels will aggravate heart failure and angina on exertion. So it should be corrected.
Exercise stress testing Exercise stress testing is an important and safe investigation in asymptomatic severe AS. Exercise stress testing
Exercise stress testing is an important and safe investigation in asymptomatic severe AS.
Trans esophageal Echo cardiogram This will help to rule out or to diagnose infective endocarditis, so it can be treated prior to the surgery. Trans esophageal Echo cardiogram
This will help to rule out or to diagnose infective endocarditis, so it can be treated prior to the surgery.
2D Echo cardiogram People with increased risk to develop AS (Congenital bicuspid aortic valve, History of rheumatic carditis) can be screened.
The valve surface area can be detected and the severity of the lesion can be categorized.
2D Echo cardiogram
People with increased risk to develop AS (Congenital bicuspid aortic valve, History of rheumatic carditis) can be screened.
The valve surface area can be detected and the severity of the lesion can be categorized.

Management - Supportive

Fact Explanation
Treat anemia Anemia can worsen the heart failure, and may precipitate angina. Treat anemia
Anemia can worsen the heart failure, and may precipitate angina.
Treat Infective Endocarditis (IE) If IE is present antibiotic treatment should be initiated. Treat Infective Endocarditis (IE)
If IE is present antibiotic treatment should be initiated.
Antibiotic prophylaxis against IE Routine use of prophylactic antibiotics is not recommended. However it is indicated when the risk of IE is high. Eg: Presence of prosthetic heart valves, history of IE, congenital cyanotic heart diseases which are not repaired.
Once a prosthetic heart valve is being placed the patient should be on life long warfarin and antibiotic prophylaxis against IE when there is a significant risk of septicemia.
Antibiotic prophylaxis against IE
Routine use of prophylactic antibiotics is not recommended. However it is indicated when the risk of IE is high. Eg: Presence of prosthetic heart valves, history of IE, congenital cyanotic heart diseases which are not repaired.
Once a prosthetic heart valve is being placed the patient should be on life long warfarin and antibiotic prophylaxis against IE when there is a significant risk of septicemia.
Management of heart failure If heart failure is present it should be managed concurrently with aortic stenosis. Management of heart failure
If heart failure is present it should be managed concurrently with aortic stenosis.

Management - Specific

Fact Explanation
Aortic valve replacement Asymptomatic patients are best managed in this way and has a good outcome.
This shows a symptomatic improvement and an increase in survival in patients with angina, dyspnea, or syncope.
There is no age limit for aortic valve replacement in patients with aortic stenosis provided there are no other comorbid conditions.
Aortic valve replacement
Asymptomatic patients are best managed in this way and has a good outcome.
This shows a symptomatic improvement and an increase in survival in patients with angina, dyspnea, or syncope.
There is no age limit for aortic valve replacement in patients with aortic stenosis provided there are no other comorbid conditions.
Per cutaneous balloon aortic valvotomy Balloon valvotomy can be done as a temporary method of relieving the symptoms in symptomatic patients who are not initially candidates for AVR. Once the symptoms are controlled definitive surgery can be performed. Per cutaneous balloon aortic valvotomy
Balloon valvotomy can be done as a temporary method of relieving the symptoms in symptomatic patients who are not initially candidates for AVR. Once the symptoms are controlled definitive surgery can be performed.

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