Aortic Stenosis

Bernardo D. Morantte Jr. M.D.

Dept. of Medicine
College of Medicine
Pamantasan Ng Lungsod Ng Maynila
 Aortic stenosis
 It is the narrowing of theaortic valve
orifice which causes an obstruction to the
flow of blood from the left ventricle (LV) to
the aorta (Ao).
 Left Heart in aortic stenosis

EKG

VA = 2cm2
LA
Aorta 2

1
Mitral valve
VA =4 cm2

 Aortic valve LV
Aortic Stenosis 2
 Etiology of Aortic stenosis
1. Congenital
Valvular _ bicuspid aortic valve (common)
Subvalvular
Supravalvular
5. Degenerative
6. Rheumatic fever
7. Connective tissue disease or collagen vascular
disease _ SLE
 Pathophysiology
 Normal aortic valve area is 2 cm2

 The wear and tear effect causes the valve

leaftlets to become rigid and calcified

 As the valve orifice narrows, the pressure in the

LV rises and a pressure gradient occurs
between the LV and the aorta.

 A pressure gradient is the difference in the

pressure (mm Hg) inside the LV and the aorta
 PATHOPHYSIOLOGY
 LV pressure LA pressure CHF

LVH LA dilatation &

hypertrophy
Pulmonary
Reduced CO hypertension

Pulmonic regurg
Hypotension
RV dilatation

Tricuspid regurg
 Symptoms of AS
 Mild to moderate aortic stenosis are
usually asymptomatic
 Angina like chest pain
 Easifatigability
 Dyspnea/ orthopnea/ PND
 Exertional Syncope
 Physical Exam
 Pulsus tardus in the carotid artery
 Thrill and harsh crescendo-decrescendo
systolic murmur at the 2nd RICS
 Early systolic click is present if valve is still
pliable
 Single S2 or paradoxical splitting of S2
 S4 present
 S3 when LV dilatation and CHF occurs
 Diffferential Diagnosis
 Hypertrophic obstructive cardiomyopathy
 Pulmonic stenosis
 VSD
 Mitral regurgitation
 Carotid artery stenosis
 Benign systolic murmur

The location and quality of the murmur differentiates it from the

above conditions.
 Diagnostics
 EKG _ LVH, LAH
 LV strain pattern ( ST depression)

 CXR_ normal heart size

 dilated aorta
 LA enlargement
 enlarge heart ushers the onset of
CHF
 Echocardiography
 Bicuspid aortic valve
 Deformed and calcified aortic valve
 Reduced aortic valve opening
 Left ventricular hypertrophy and left atrial
dilatation
 Ejection fraction (EF) usually normal (55 % or >)
but declines with the onset of CHF
On Doppler
 Increased velocity at the aortic valve
 usually 4 m/ sec or >

Gradient = 4 V square
 Ejection Fraction
 EF = EDV - ESV %

 Cross sectional view of Left ventricle (LV)

 End diastolic volume (EDV) End systolic volume (ESV)

 Cardiac Catheterization
 Clinically significant AS _presence of
pressure gradient of 50 mm Hg or higher
at rest in a patient with normal cardiac
output
 Severe aortic stenosis = Aortic valve area
of < 1 cm2 or < 0.75 cm2/m2
 Complications
 Endocarditis
 Congestive Heart Failure
 Cardiac arrhythmia
 Sudden death
 Natural History of Aortic Stenosis
from onset of symptoms
Death
 Angina pectoris 3 years
 Syncope 3 years
 Dyspnea 2 years
 CHF 1.5 -2 years
 Medical Management
 Restriction of sports and strenuous physical activity
 Importance of fluids or hydration in the absence of CHF
 Treatment of Cardiac arrhythmias
 Cautious use of NTG for angina
 Ace Inhibitors have unproven long term benefits_ risk of syncope!
 SBE prophylaxis

 Balloon valvuloplasty for severe aortic stenosis with pliable leaflets

especially in children and young adults

 DON’TS
 Digitalis is contraindicated except for control of SVT or A-fib
 Treadmill exercise test is contraindicated in severe aortic stenosis
 Indications for intervention or
surgery
 Presence of symptoms assuming that
there are no other explanation for the
symptoms

 Aortic valve area of < 1 cm2 or less

 Surgical Therapy
 Aortic valve replacement for valvular aortic
stenosis with:
 Bioprosthesis
 Mechanical valves

 Open incision or excision for subvalvular or

supravalvular aortic stenosis

 Surgical mortality 8%
 For patients with reduced EF or CHF, surgical
mortality is 20 %
 Survival rate after AVR
 60 % 10 year survival

 With bioprosthesis 30% requires repeat
valve replacement after 8-10 years
END of Aortic Stenosis
 Aortic regurgitation (AR)
 It is the backward flow of blood from the
aorta to the left ventricle (LV) in diastole

 It is also known as aortic insufficiency (AI)

 Left Heart _ Aortic regurgitation

EKG
LA
Aorta VA = 2cm2
Mitral valve
2

VA =4 cm2

Aortic valve LV
 Pathophysiology
 Left ventricular volume = Regurgitant
volume from the aorta + forward volume
from the left atrium
 Pathophysiology of AR
 LV volume

 LA dilatation
 LV dilatation
 LA pressure
 LV stroke volume
 CHF
 Aortic dilatation
 Etiology of aortic regurgitation
Acute Chronic
 Acute / subacute  Congenital

endocarditis  Rheumatic heart

 Trauma disease
 Connective tissue
 Aortic dissection /
disease such as
Marfan’s syndrome Rheumatoid arthritis
ankylosing spondylitis
Lupus Erythematosus
 Syphilis
 Symptoms
Early Late
 Asymptomatic  Easifatigability
 Awareness of heart  Exertional dyspnea
beats or palpitation  Orthopnea / PND
 Edema
 Chest pains
 Physical examination
 Systolic hypertension
 Wide pulse pressure
 Besferiens and waterhammer pulse (Corrigan’s)
 Hyperdynamic precordium and apical impulse is displaced to the left and
inferiorly
 Thrill and a diastolic blowing murmur at the 3rd LICS or 2nd RICS
 S3
Plus the findings below in moderately severe to severe AR
 Head bobbing
 suprasternal notch pulsation (aortic dilatation)
 Diastolic murmur at the apex ( Austin flint murmur)
 Pistol shot (Traube sign)
 Dorosiez sign
 Quinke’s pulse
 Signs of CHF
 Differential Diagnosis
 Pulmonic regurgitation
 Coronary sinus AV fistula
 Mitral stenosis
 Aortic dissection
 DIAGNOSTICS
 EKG _ LVH, LAH
LBBB

 Chest x-ray
• cardiomegaly with the apex displaced
downward and to the left
• Left atrial enlargement
• dilated aorta
 Echocardiogram
 Deformed aortic leaflets
 Presence of calcification suggest a combined
AS/ AR lesion
 Austin Flint phenomena in the mitral valve
 LV and LA dilatation
 Initially EF is normal or increased
 Doppler
 Presence of regurgitant jet flow from aorta to LV
 Chest CT scan
 To exclude aortic dissection if patient
presents with chest pains
 Markedly dilated aorta
 Following severe chest trauma
 Cardiac Cath
 Aortic root angiography

Backflow of x-ray contrast material

from the aorta to the LV

Aortic root angiography is relatively

contraindicated in the presence of aortic
dissection
 Other diagnostic studies
 RA factor
 ANA titer and LE prep
 VDRL and RPR
 Blood cultures for febrile patients
 Medical therapy
 Fluid and salt restriction
 Ace inhibitors
 Digoxin
 Duiretics
 Treat cardiac arrhythmias if present
 SBE prophylaxis with appropriate antibiotics

Depending on the history, PE and results of diagnostic test:

 Rheumatic fever prophylaxis
 Antibiotic therapy for endocarditis
 Penicillin therapy for syphilis
 Steroid therapy for connective tissue disease
 Indications for surgery in AR
 Class III-VI functional capacity
 EF< 55 %
 LV end systolic volume of 55 ml /m2 or > in
the echocardiogram
 Surgical therapy
 Aortic valve replacement

Bioprosthesis
Mechanical valve


 END