Aortic stenosis is one of the most common and most serious valve disease problems.

Aortic stenosis is one of the most common and most serious valve disease problems. 
Aortic stenosis is a narrowing (3-4cm2 )of the aortic valve opening.
 Aortic stenosis restricts the blood flow from the left ventricle to the aorta and may also affect the pressure in the left atrium.
Congenital aortic valve stenosis develops progressively because of turbulent blood flow through a congenitally abnormal (usually bicuspid) aortic valve

1. Aortic Valve disease DR: SanaIhsan

2. Aortic stenosis  is one of the most common and most serious valve disease problems.  Aortic stenosis  is a narrowing (3-4cm 2 )of the  aortic  valve opening.   Aortic stenosis  restricts the blood flow from the left ventricle to the  aorta  and may also affect the pressure in the left atrium. Congenital aortic valve stenosis develops progressively because of turbulent blood flow through a congenitally abnormal (usually bicuspid) aortic valve

3. Causes  Rheumatic fever results in progressive fusion, thickening and calcification of a previously normal three-cusped aortic valve. In rheumatic heart disease the aortic valve is affected in about 40% of cases and there is usually associated mitral valve disease. Calcific valvular disease is the commonest cause of aortic stenosis and mainly occurs in the elderly. This is an inflammatory process involving macrophages and T lymphocytes with initially thickening of the subendothelium with adjacent fibrosis. The lesions contain lipoproteins which calcify, increasing leaflet stiffness and reducing systolic opening

4. Causes

5. Pathophysiology Obstructed left ventricular emptying leads to increased left ventricular pressure and compensatory left ventricular hypertrophy . In turn, this results in relative ischaemia of the left ventricular myocardium , and consequent angina , arrhythmias and left ventricular failure . The obstruction to left ventricular emptying is relatively more severe on exercise. Normally, exercise causes a many-fold increase in cardiac output, but when there is severe narrowing of the aortic valve orifice the cardiac output can hardly increase.

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7. Investigations Chest X-ray: The chest X-ray usually reveals a relatively small heart with prominent, dilated, ascending aorta.  This occurs because turbulent blood flow above the stenosed aortic valve produces so-called ‘post-stenotic dilatation’.  The aortic valve may be calcified Electrocardiogram:  left ventricular hypertrophy   A left ventricular ‘ strain’ pattern ( depressed ST segments and T wave inversion in leads orientated towards the left ventricle, i.e. leads I, AVL, V5 and V6) .  Sinus rhythm is present, but ventricular arrhythmias may be recorded.

8. Echocardiogram: The echocardiogram readily demonstrates the thickened , calcified and immobile aortic valve cusps. Left ventricular hypertrophy may also be seen. The gradient across the valve can be estimated by CW Doppler, provided the left ventricular function is reasonable

9. Treatment Provided that the valve is not severely deformed or heavily calcified, critical aortic stenosis in childhood or adolescence can be treated by valvotomy (performed under direct vision by the surgeon or by balloon dilatation using X-ray visualization). This produces temporary relief from the obstruction. Aortic valve replacement will usually be needed a few years later. Balloon dilatation (valvuloplasty) has been tried in adults, especially in the elderly, as an alternative to surgery.

10. Percutaneous valve replacement A novel treatment for patients unsuitable for surgical aortic valve replacement is transcatheter implantation with a balloon expandable stent valve. In a recent study valve implantation was successful (86%) with a procedural mortality of 2% and 30-day mortality of 12%

11. AORTIC REGURGITATION Aortic insufficiency  (AI), also known as  aortic regurgitation (AR), is the leaking of the  aortic  valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the  aorta  into the left ventricle The most common causes of aortic regurgitation are rheumatic fever and infective endocarditis complicating a previously damaged valve This can be a congenitally abnormal valve (e.g. a bicuspid valve) or one damaged by rheumatic fever

12. causes Acute rheumatic fever Hypertension Bicuspid aortic valve Rheumatic heart disease Infective endocarditis

13. Pathophysiology Aortic regurgitation is reflux of blood from the aorta through the aortic valve into the left ventricle during diastole. If net cardiac output is to be maintained, the total volume of blood pumped into the aorta must increase, and consequently the left ventricular size must enlarge. Because of the aortic run off during diastole, diastolic blood pressure falls and coronary perfusion is decreased. In addition, the larger left ventricular size is mechanically less efficient so that the demand for oxygen is greater and cardiac ischaemia develops.

14. Symptoms a common symptom is ‘ pounding of the heart ’ because of the increased left ventricular size and its vigorous pulsation.  Angina pectoris is a frequent complaint.  Varying grades of dyspnoea Arrhythmias are relatively uncommon. Signs: The pulse is bounding or collapsing

15. Quincke’s sign – capillary pulsation in the nail beds  De Musset’s sign – head nodding with each heart beat Duroziez’s sign – a to-and-fro murmur heard when the femoral artery is auscultated with pressure applied distally (if found, it is a sign of severe aortic regurgitation) Pistol shot femorals – a sharp bang heard on auscultation over the femoral arteries in time with each heart beat The apex beat is displaced laterally and downwards and is forceful in quality

16. AUSCULTATIONS There is a high-pitched early diastolic murmur best heard at the left sternal edge in the fourth intercostal space with the patient leaning forward and the breath held in expiration.

17. Investigations Chest X-ray The chest X-ray features are those of left ventricular enlargement and possibly of dilatation of the ascending aorta . The ascending aortic wall may be calcified in syphilis , and the aortic valve may be calcified if valvular disease is responsible for the regurgitation. Electrocardiogram The ECG appearances are those of left ventricular hypertrophy due to ‘volume overload’ – tall R waves and deeply inverted T waves in the left-sided chest leads, and deep S waves in the right-sided leads. Normally, sinus rhythm is present.

18. Echocardiogram The echocardiogram demonstrates vigorous cardiac contraction and a dilated left ventricle. The aortic root may also be enlarged. Diastolic fluttering of the mitral leaflets or septum occurs in severe aortic regurgitation (producing the Austin Flint murmur). The regurgitant jet can be detected by CW Doppler.

19. Treatment The underlying cause of aortic regurgitation (e.g. syphilitic aortitis or infective endocarditis) may require specific treatment. The treatment of aortic regurgitation usually requires aortic valve replacement but the timing of surgery is critical. Because symptoms do not develop until the myocardium fails and because the myocardium does not recover fully after surgery, operation is performed before significant symptoms occur

20. Both mechanical prostheses and tissue valves are used. Tissue valves are preferred in the elderly and when anticoagulants must be avoided, but are contraindicated in children and young adults because of the rapid calcification and degeneration of the valves. Antibiotic prophylaxis against infective endocarditis is sometimes necessary if a prosthetic valve replacement has been performed