Aortic stenosis

Anatomy of aortic valve and aortic stenosis - discussion in medicine

1. AORTIC VALVE – ANATOMY & AORTIC STENOSIS

2. STRUCTURE OF AORTIC VALVE 3 SEMILUNAR CUSPS

3. Cusps are attached directly to the vessel wall Nodule Lunule Aortic sinuses - coronary arteries arise from anterior and left posterior aortic sinuses

4. Structure of aortic valve

5. Narrowing of the valve orifice due to fusion of cusps is known as – stenosis Dilatation of the valve orifice or stiffening of the cusps causes imperfect closure of valves leading to back flow of blood – incompetence or regurgitation

6. AORTIC STENOSIS Occurs in one fourth of all patients with chronic valvular heart disease 80% of adult patients with symptomatic AS are male

7. CAUSES Infants, children, adoloscents Congenital aortic stenosis Congenital subvalvular aortic stenosis Congenital supravalvular aortic stenosis

8. Young adults to middle aged Calcification and fibrosis of congenitally bicuspid aortic valve Rheumatic aortic stenosis Middle aged to elderly Senile degenerative aortic stenosis Calcification of bicuspid valve Rheumatic aortic stenosis

9. Congenital (bicuspid, unicuspid ) Degenerative calcific Rheumatic fever Radiation

10. Pathogeensis Initially cardiac output is maintained by steady increase in pressure gradient across aortic valve LV hypertrophy and coronary blood flow inadequate to supply the myocardium- angina LV failure and pulmonary edema

11. Symptoms Cardinal symptoms are angina,breathlessness and syncope Mild or moderate stenosis: usually asymptomatic Exertional dyspnoea Angina Exertional syncope Sudden death Episodes of acute pulmonary edema

12. Signs Ejection systolic murmur Pulsus parvus et tardus Slow rising carotid pulse A thrill or anacrotic shudder over carotid arteries a wave in the jvp is accentuated Thrusting apex beat Narrow pulse pressure Signs of pulmonary venous congestion

13. LV impulse is usually displaced laterally Double apical impulse (with a palpable S4)

14. Auscultation Ejection systolic murmur Paradoxical splitting of S2 S4 is audible at the apex

15. Investigations ECG Left ventricular hypertrophy – ST segment depression and T wave inversion (LV strain) in lead I and aVL Left bundle branch block Chest X ray May be normal; sometimes enlarged left ventricle and dilated ascending aorta on postero -anterior view, calcified valve on lateral view

16. Echocardiogram Calcified valve with restricted opening, hypertrophied left ventricle Doppler Measurement of severity of stenosis(systolic gradient across the aortic valve) Detection of associated aortic regurgitation Cardiac catheterisation Mainly to identify associated coronary artery disease May be used to measure gradient between left ventricle and aorta

17. Natural history Average time to death after the onset of various symptoms Angina – 3 years Syncope – 3 years Dyspnoea – 2 years Congestive heart failure – 1.5 to 2 years

18. Medical treatment Nitroglycerin Beta blockers , ACE inhibitors Statins

19. Surgical – aortic valve replacement Percutaneous balloon aortic valvuloplasty Children and young adults Bridge to operation Percutaneous aortic valve replacement

20. Aortic stenosis in oldage Most common form of valve disease affecting very old Syncope, angina, heart failure Because of increasing stiffening in the central arteries, low pulse pressure and a slow rising pulse may not be present Trans catheter aortic valve implantation (TAVI) Biological valve is preferable

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