Aortic stenosis

1. Aortic stenosis Dr Husain Tayib

2. Aortic stenosis

3. *Younger people _Functional murmur vs _ MVP vs _ AS *Older people _Aortic sclerosis vs _Aortic stenosis Common Clinical Scenarios Aortic stenosis 1

4. Young patient _Thick congenital bicuspid valve *2% population *3:1 male:female *Co-existing COA 6% patients _Rarely *Unicuspid valve *supravalvular AS *Subaortic stenosis _Discrete _Diffuse { Tunnel} Middle age {40- 50y } _Thick bicuspid valve _Rheumatic disease Old age {60- 80y} _Thick degenerative valve _Calcification of bicuspid valve _Rheumatic AS 2 Aetiology Aortic stenosis

5. Aortic Stenosis Subvalvular Congenital Bicuspid Valvular (HCM; IHSS Supravalvular Dgenerative Rheumatic

6. Aortic stenosis Pathophysiology COP maintained normal for years by progressive LVH _ Coronary blood flow becomes inadequate Exertional Angina _LV outflow obstruction limits COP after exercise Exertional syncope _LVEDP raise Pulmonary congestion Dyspnoea ,Pulmonary oedema _Patients asymptomatic for long time once symptoms appear deteriorate rapidly

7. Clinical features: Aortic stenosis 4 *Cardinal Symptoms _Mild or moderate AS usually asymptomatic _Chest pain (angina) Rreduced coronary flow reserve Increased demand-high afterload _Syncope/Dizziness (exertional pre-syncope) Fixed cardiac output Vasodepressor response _Dyspnoea on exertion & rest Impaired exercise tolerance _Episodes of acute pulmonary oedema _Sudden death *Other signs of LV failure Diastolic & systolic dysfunction

8. 5 Aortic stenosis Clinical features cont.. *Signs _Ejection systolic murmer _Slaw rising carotid pulse _Narrow pulse pressure _Thrusting apex beat { LV pressure overload } _Signs of pulmonary congestion { basal crepitation }

9. Auscultation : Aortic stenosis 6 S1 S2 S1 S2 Mild-Moderate Severe

10. Some points about physical signs : Aortic stenosis 7 _Intensity DOES NOT predict severity _Presence of thrill DOES NOT predict severity Conditions indicating severity: _”Diamond” shaped, harsh, systolic crescendo- decrescendo {Long murmer} _Decreased, delay & prolongation of pulse amplitude {Anacrotic pulse } _Paradoxical S2 _S4 (with left ventricular hypertrophy) _S3 (with left ventricular failure)

11. Aortic stenosis 8 Investigations : * ECG _ LVH _ LBBB _May be normal * Chest XR _Enlarged LV _Dilated Ascending aorta _May be normal _Calcified AV * ECHO _Calcified AV with restricted opening _Thickened LV walls *Dopler _ Estimates gradient _detects AR *Cardiac Catheterization : _Systolic gradient between LV and Aorta _Post-stenotic dilatation of aorta _Detects AR if present _To detect presence of CAD

12. ECG Aortic stenosis 9 V1

13. 10 Aortic stenosis PALL Chest X-ray

14. Aortic stenosis 11 Subvalvuler Calcified cusps 2-d ECHO LX

15. Aortic stenosis CW-dopler CFM

16. Natural history Aortic stenosis 12 _Heart failure reduces life expectancy to less than 2 years _Angina and syncope reduce life expectancy between 2 and 5 years _Rate of progression  @ 0.1 cm2/year

17. ECHO (cont.) • Criteria for determining severity of AS

18. Aortic stenosis Management : *Medical _Prophylaxis against IE _ Anticoagulants if in AF _Diuretics cautiously for pulmonary congestion _Vasodilators are CONTRAINDICATED * Surgical _ Patients with symptoms and valve gradient >50 and normal COP should have AV replacement { Mechanical } _ Symptomatic Elderly patients need AV replacement with {Bioprosthesis} _ Aortic Balloon valvoplasty for congenital AS

19. 16 Disc Valve Aortic stenosis Artificial valves Bio-prosthetic Valve Caged-Ball Valve

20. * MECHANICAL _Durable _Large orifice _High thromboembolic potential _Best in Left Side _Chronic warfarin therapy BIO-PROSTHETIC _Not durable _Smaller orifice/functional stenosis _Low thromboembolic potential _Consider in elderly _Best in tricuspid position Comparison between Mechanical and Prosthetic Valves Aortic stenosis 18

21. Common Murmurs and Timing (click on murmur to play) Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis S1 S2 S1

22. Thank you