Aortic stenosis

Aortic stenosis is a valvular heart disease resulting in reduction of blood flow to the body and making the heart work harder. The heart may weaken causing chest pain, fatigue and shortness of breath.

1. AORTIC STENOSIS DR. KALPANA CHETIA ASSOC. PROF OF MEDICINE JMCH

2. Valvular Subvalvular Supravalvular CLASSIFICATION

3. Rheumatic – seen in adolescence or adulthood. Congenital – seen in childhood, can be supravalvular , valvular and subvalvular , may be associated with bicuspid aortic valve. Calcified AS – seen in elderly Aortic sclerosis – rheumatic AS is usually accompanied by either AR or MV disease. Valvular aortic stenosis . A) etiology

4. CAUSES OF AS

5. chest pain as the heart strains to pump enough blood through the compromised valve feeling tired after exertion, as when you exercise or move feeling short of breath, especially after exertion heart palpitations , or abnormal heartbeats a heart murmur , which is an abnormal swooshing sound produced by the heart as it beats C/F

6. Most patients with aortic stenosis develop one or more of these three classic symptoms : shortness of breath, loss of consciousness, and chest pain. Thickening of the walls of the left ventricle causes the ventricle to become stiff and unable to relax between contractions. When this happens, the pressure in the left ventricle rises and blood can "back up" into the lungs, interfering with normal absorption of oxygen from the lungs into the bloodstream. This may cause shortness of breath , which worsens as the left ventricle becomes increasingly impaired.

7. Patients with aortic stenosis may also experience chest pain , pressure, or discomfort (called angina or angina pectoris ), caused by an insufficient supply of oxygen to the heart. As the left ventricle thickens and works harder to expel blood through the stenotic aortic valve, its demand for oxygen increases.

8. Low bp Low pulse pressure Low volume slow rising sustained pulse Systolic thrill at aortic area Systolic murmur conducted to carotids Cardiomegaly Heaving apex beat Basal crepitations SIGNS

9. Electrocardiogram – LVH with strain pattern , LBBB, complete heart block . Chest x-ray – rounded apex, cardiomegaly , post stenotic dilatation of AA, calcified aortic valve. 2D Echo- LVH, calcified aortic valve, gradiat measurement to assess severity. Cardiac cathetarisation - to estimate gradient across aortic valve and detect AR if present. Coronary angiography – to detect CAD before surgery. INVESTIGATIONS

10. LVF rapidly progressive Right ventricular failure – end stage indicates poor prognosis. Sudden death due to arrhythmias ( ventricular fibrillation ) Complete heart block Infective endocarditis Hemolysis Aortic dissection . COMPLICATIONS

11. Treatment of LVF Rheumatic fever and IE prophylexis Beta-blockers to reduce HR, improve coronary artery blood flow in patients with IHD. Statins for AS due to aortic sclerosis MEDICAL MANAGEMENT

12. BALLOON AORTIC COMMISSUROTOMY OR OPEN HEART AORTIC VALVE COMMISSUROTOMY If associated with AI aortic valve replacement If associated with MS both aortic valve and MV should be operated simultaneously Balloon valvotomy – indications are mainly in children and young adults with congenital AS, in elderly unfit for surgery, as a temporary measure in unstablepatients . SURGICAL TREATMENT

13. Murmur- longer the murmur and later the peaking of murmur , more severe the AS. A2 followed by P2 ( MILD AS) , delayed A2 – merging with P2 single S2 ( moderate AS) , A2 following P2 –reversed splitting ( severe AS ) S4 audible and absent A2 – severe AS. S3 audible – severe systolic dysfunction Q- how will you assess severity of AS

14. Mild- less than 30 mm of Hg . Moderate – 30 -50 mm of Hg. Severe – greater than 50 mm of Hg . Gradient across aortic valve

15. Normal aortic valve area 3-4 cm2 / m2 body surface area . Mild AS- 1-2 cm2 /m2 body surface area. Severe AS less than 0.75 cm2/m2 body surface area Critical AS – less than 0.5 cm2 /m2 body surface area. Measurement of aortic valve area

16. Functional in severe AR. Sclerotic aortic valve Coarctation of aorta VSD murmur MR murmur transmitted to base of heart Syphilitic aortitis Supravalvular AS , Subvalvular intrinsic hypertrophic AS . What is the d/d 0f systolic murmur in aortic area