Aortic stenosis for post graduates

aortic stenosis
cases

1. MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI,
FCCP, FAPSC, FAPSIC, FAHA, FACP, FASE
Professor and Head of Cardiology
Colonel MalekMedical College , Manikganj.
For post-graduates
[email protected]/8/2019
Post graduate version 2019

2. Case report-01
•A 63 years old gentleman presented several times
of syncope with shortness of breath on exertion for
last 2 years , increasing in intensity for last 3
months. On examination he is dysnoeic, pulse-
128/min, small volume, BP-90/60 mm Hg, RR-
32/min, systolic thrill in aortic area and all over the
precordium, ECG-LVH, CXR-P/A view-Cardiomegaly,
Echocardiogram-severe aortic stenosis and suitable
candidate for TAVI. Patient underwent TAVI and
now he is doing well.
8/17/2019
Col. Malek Medical College, Manikganj
[email protected]
2
Mitral Stenosis
Aorticstenosis

3. Case report-02
•A 53 years old gentleman presented with shortness of
breath on exertion for last 2 years , increasing in
intensity for last 3 months. On examination she is
dysnoeic, pulse-128/min, irregular, BP-100/30 mm Hg,
RR-32/min, diastolic thrill in apex, mid-diastolic
murmur in apical area, early diastolic murmur in left
lower sternal area and systolic murmur in aortic area.
ECG-Atrial Fibrillation, CXR-P/A view-Cardiomegaly,
Echocardiogram-severe mitral stenosis with Moderate
AS with severe AR with moderate pulmonary
hypertension. Patient underwent DVR and she is doing
well.
8/17/2019
Col. Malek Medical College, Manikganj
[email protected]
3
Mitral Stenosis
Aorticstenosis

4. Aorticstenosis

5. Aorticstenosis

6. Aorticstenosis

7. Normal valve function
•Maintain forward flow and prevent
reversal of flow.
•Valves open and close in response to
pressure differences (gradients) between
cardiac chambers.

16. Essential questions in the evaluation of
patients for valvularintervention

17. Diagnosis
•History
•Physical examination
•ECG
•Chest x-ray
•Echocardiography
•Invasive evaluation, CT,
MRI

18. History
•Generally: symptoms of heart failure
and low cardiac output
•Breathlessness
•Chest pain or dyscomfort
•Syncope
•Fatigue
•Peripheral or pulmonary oedema
•Palpitations

19. Physical examination
•MURMURS!!!
•Periferaloedema
•Lungcrackles
•ElevatedJVP
•Displacedapex beat,
irregularheartbeat…
Hundredsofeponymoussignsfrompast
millenium (↓importancein daily
routine, ↑importanceforpassingexam)

20. Heart murmurs
•Sounds produces by turbulent
blood flow (in valve diseseses,
artery stenosis, abnormal
chamber or AVcommunication)
•Localization,grade,
propagation, timing, quality

21. Heart murmurs
Intensity Description
Grade I/VI Barelyaudible
Grade II/VI Audible,butsoft
Grade III/VI Easilyaudible
Grade IV/VI Easilyaudible, associatedwitha thrill
Grade V/VI Easilyaudible, associatedwitha thrill,andstillaudiblewiththe
stethoscopeonlylightlyon thechest
Grade VI/VI Easilyaudible, associatedwitha thrill,andstillaudiblewiththe
stethoscopeoffofthechest

22. Aortic stenosis
•Common indication for valve intervention
•Causes
•Degenerativeaorticstenosis
•Bicuspidaorticvalve
•Congenitalaorticstenosis, unicuspidaorticvalve
•Rheumaticdisease(alwayswithmitralvalve
involvement)
•Infectiveendocarditis(butsevere stenosis dueto
massivevegetationsisextremelyrare)
•Otherrare causes –post radiation, associated
withsystemicdisease
Aorticstenosis
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23. Aorticstenosis

24. Aorticstenosis

25. Aorticstenosis

26. Aorticstenosis

27. Aortic stenosis
•Pathophysiology
•Normal aortic valve area (AVA) –3-4 cm
2
•With a decrease of AVA ,apressure
gradient develops between the left
ventricle and the aorta (increased
afterload)
•LV function initially maintained by
compensatory concentric hypertrophy
(but without an adequete increase in
vascularization)
•When compensatory mechanisms are
exhausted, LV function declines.
Aorticstenosis
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28. Aorticstenosis
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29. Aortic stenosis
Presentation
•Anginapectoris(increased myocardial oxygen
demand; demand/supply mismatch)
•Dyspnea on exertion due to heart failure (systolic
and diastolic)
•Syncope(exertional)
•Sudden death, mortality –whenasymptomatic
withpreservedleftventricleejctionfraction, the
suddendeathrisk isabout1%/y, when
symptomatic, however, themortality increasesto
upto 50%/y
Aorticstenosis
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30. Aortic stenosis
Physical finding
•Systolic crescendo-decrescendo murmur with
maximum at right sternal border, 2nd-3rd intercostal
space , propagated to the carotic arteries –the
loundness of the murmur is not directly correlated to
severity of stenosis
•Slow rising carotid pulse (pulsustardus) & decreased
pulse amplitude (pulsusparvus)
•Heart sounds-soft and split second heart sound, S4
gallop due to LVH…
Aorticstenosis
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32. Aorticstenosis

33. Aorticstenosis

34. Aorticstenosis

35. Aorticstenosis

36. Stepwise integrated approach
for the assessment of aortic
stenosis severity. Pseudosevere
AS is defined by an increase to
an AVA >1.0cm
2
with flow
normalization.

37. Criteria that increase the likelihood of severe aortic stenosis
in patients with AVA <1.0cm2 and mean gradient <40mmHg
in the presence of preserved ejection fraction
Aorticstenosis
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38. Aorticstenosis
Therapy –medical therapy has no prognostic
effect
•Aortic valve replacement
•Standard therapy for patients with low
surgical risk or with indication for other
procedure
•Mechanical/biological prosthesis
•TAVI (transcatheter aortic valve implantation) –
patiens at unaccaptable surgical risk (elderly,
comorbid)
•Percutaneous aortic balloon valvuloplasty (for
congenital stenosis, or as a bridging therapy for
unstable patients)
Aorticstenosis
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39. Indicationforreplacement
•Severe aorticstenosis (AVA <1 cm
2
, mean
PG >40mmHg)
•Symptomatic
•LV functiondecreases
•Otherindicationforsurgery
•Moderate stenosis (AVA 1,5-1 cm
2
)
•Withotherindicationforsurgery
Aorticstenosis
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40. Management of severe aortic stenosis

41. Aorticstenosis
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42. Aorticstenosis

43. Aorticstenosis

45. [email protected]

46. [email protected]

47. [email protected]

49. Target INR for mechanical prostheses
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50. Recommended requirements of a heart valve Centre

51. Aorticstenosis