Aortic Stenosis

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Aortic Stenosis

Causes

• congenital
  • bicuspid valves
• inflammatory
  • Rheumatic Fever
• calcific
  • age

Pathology

• Obstruction of LV emptying
  • LV hypertrophy
  • end diastolic pressure increased
    •  fibrosis
    • subendocardial ischaemia
    • mitral regurgitation
  • reduced stroke volume
  • reduced cardiac output
  • HR (?)

Bicuspid aortic valve

• usually presents in men 40-60 years
• 2% population
• 1 female : 3 male
• almost always develop stenosis
• peak symptoms develop at 40-60 years
• 5 years between onset symptoms and death
• 2 types
  1. right and left
     • right has raphe
  2. anterior and posterior
     • coronary arteries come from anterior cusp

History

• often male
• Chest Pain
• exertional dyspnoea
• syncope
  • fixed cardiac output
  • abnormal baroreceptor response
  • VT/VF, bradyarrhythmias
  • GI bleeds
  • angiodysplasia
• fatigue
• congestive heart failure
• angina
• sudden death

Examination

• Hands
• Pulse
  • sinus rhythm
• BP
  • low systolic
  • narrow pulse pressure
• Neck
  • carotid pulse
    • slow rising
    • small volume
    • thrill
• Face
• Praecordium
  • Inspect
    • visible apex beat
  • Palpate
    • undisplaced, heaving Apex beat
    • parasternal heave (left ventricular hypertrophy)
    • thrill over aortic area
  • Auscultate
    • Harsh Ejection Systolic Murmur
      • loudest in aortic area
      • often heard at apex
      • radiates to carotids
    • first sound usually normal
      • ejection click if bicuspid
    • second heart sound
      • soft
      • reverse splitting of second heart sound (A₂ after P₂ )
• Lung Bases - Normal if uncomplicated
• Pedal Oedema

Investigations

• ECG
  • left ventricular hypertrophy
• CXR
  • left ventricular hypertrophy
• Echocardiogram
• Cardiac catheterisation
  • ascending aorta dilatation
  • increased pressure gradient between LV and aorta
    • mild if gradient <25mmHg
    • moderate if gradient 25-40mmHg
    • severe if >40mmHg

Variants

• aortic sclerosis
  • pulse, bp, apex normal

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