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Cardiovascular System > Aortic Valve Stenosis-Merkin > Flashcards

Aortic Valve Stenosis-Merkin Flashcards

1
Q

Types of location aortic stenosis

A

From least to most common: Supravalvular, Descrete subvalvular (DSS), Valvular

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2
Q

In congenital aortic stenosis, which congenital cuspid state is generally involved?

A

Most severe: unicuspid. Most common: bicuspid. Also: tricuspid or fused or quadricuspid.

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3
Q

What can be seen of the valve in a longitudinal echo?

A

Only 2 cusps.

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4
Q

What can be seen in a cross-sectional/short-axis echo?

A

All 3 cusps.

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5
Q

What is seen in aortic stenosis on an echo?

A

Less laminar flow leads to turbulence, calcification and fibrosis of valve leading to AS.

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6
Q

Types of acquired aortic stenosis

A

Rheumatic, degenerative/senile (most common, increased incidence with age), atherosclerotic (usually with familial dyslipidemia

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7
Q

Pathophysiology of aortic valve disease

A
  1. Gradual obstruction of LV outflow, 2. Increased intraventricular pressure, 3. Concentric LVH, 4. Maintained CO with increased EDP
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8
Q

In severe aortic stenosis, what usually brings on symptoms?

A

CO fails to rise normally during exercise. Later, CO declines at rest and CHF ensues.

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9
Q

Clinical manifestations of aortic stenosis

A

Long latent period, cardinal manifestations: angina pectoris (d/t decreased coronary flow, usually only on exercise), syncope (can’t increase circulation to brain effectively), heart failure (dyspnea d/t LVF)

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10
Q

What appears on a physical exam of aortic stenosis?

A

Pulsus tardus and parvus, systolic thrill, A2, ejection systolic mumur

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11
Q

Pulsus tardus et parvus

A

Upstroke of pulse is slow and weak/small.

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12
Q

What is systolic thrill?

A

Flow through valve turbulant, fingers over aortic oscultation point will be able to feel thrill (murmur).

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13
Q

Heart sounds in aortic stenosis

A

S2 will be increased in a young person whose valve is still pliable, in elderly person will be calcified and more muffled. Sometimes hear S4 sound.

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14
Q

Aortic stenosis murmur

A

Middle of systole, diamond shaped (louder then softer)

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15
Q

What lab tests should be performed in aortic stenosis?

A

ECG (LVH, conduction abnormalities), CXR, angiography, Echo

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16
Q

What test is done to follow up on aortic stenosis patients?

A

Echo, angiography is too invasive and expensive.

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17
Q

What is the definition of a mild aortic stenosis?

A

Jet velocity 1.5cm^2

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18
Q

What is the definition of severe aortic stenosis?

A

Jet velocity >4.0, Mean gradient >40mmHg, Valve area

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19
Q

What is the medical management of aortic stenosis?

A

Report symptoms, repeat echo, antibiotic propphylaxis not usually recommended. No medical treatment to prevent progression.

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20
Q

What is the primary determinant for need for aortic valve replacement?

A

Symptoms. No treatment for asymptomatic patient unless LV dysfunction.

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21
Q

What related condition should be treated with aortic stenosis?

A

Left ventricular dysfunction. Treat with ACE inhibitors but need to be careful with increasing vasodilation not to reach syncope.

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22
Q

Without treatment, what is the prognosis for severe aortic stenosis?

A

Almost half die within a year of onset of symptoms.

23
Q

What is the surgical treatment for aortic valve stenosis that is not calcified?

A

Commissurotomy (separate cusps of valves) or balloon valvuloplasty. Not for severe cases.

24
Q

What is the surgical treatment for aortic valve stenosis that is calcified?

A

Aortic valve replacement (AVR) or Percutaneous/transapical valve implantation.

25
Q

What is the Ross procedure for AVR?

A

Remove stenosed aortic valve, take pulmonic valve into aortic and replace pulmonic valve with artificial valve.

26
Q

Why is a Ross procedure performed?

A

Pulmonic artificial valves last a while.

27
Q

When are mechanical valves used over biologic valves?

A

Aortic prosthesis don’t last very long. In young patient, biological prostehsis last 12-15 years and then degenerate. In young patient insert mechanical because last longer. In elderly give biological (porcine) valve because life expectancy is less than valve expectancy.

28
Q

What is percutaneous/transapical valve implantation?

A

Stented valve inserted via catheter while dilating old valve. Treatment for older patients that can’t tolerate surgery (not as good as surgery).

29
Q

Which is more common, aortic stenosis or regurgitation?

A

Stenosis.

30
Q

What is the prevalnce of aortic stenosis?

A

Approximately 2% of people over the age of 65, 3% of people over age 75, and 4% percent of people over age 85 have aortic valve stenosis.

31
Q

What is the etiology and pathology of aortic regurgitation?

A

Valvular disease (congenital or acquired), aortic root disease (usually Marfan syndrome)

32
Q

What is the most common etiology of aortic regurgitation?

A

Hypertension (but since so ubiquitous, no prognostic implication, many with very little regurgitation)

33
Q

Pathophysiology of aortic regurgitation

A

Increased LVEDV. Increased effective stroke volume and EF, eccentric hypertrophy, late in course EF declines at rest and ESV increases.

34
Q

Where does the volume overload come from in aortic regurgitation?

A

Blood goes back to LV from aorta during diastole, dilates in compensation.

35
Q

What is the consequence on the LV as a result of longstanding aortic regurgitation?

A

Dilatation and eccentric hypertrophy.

36
Q

Why is there LV hypertrophy in aortic regurgitation?

A

Compensation to maintain CO and increase SV. While compensating, asymptomatic.

37
Q

What happens late in severe aortic regurgitation after compensation is no longer possible?

A

EF declines and ESV increases leading to heart failure.

38
Q

What is the pathophysiology of acute AR?

A

No LV addaptation, failure of SV to compensate and CO decreases and LVEDV increases rapidly.

39
Q

What is the consequence of high diastolic pressure in severe aortic regurgitation?

A

Pulmonary edema, cardiogenic shock. CO doesn’t meet needs.

40
Q

What are the causes of acute aortic regurgitation?

A
  1. Endocarditis, 2. Dissection of ascending aorta (splits valve causing leaking)
41
Q

Clinical manifestations of chronic severe aortic regurgitation?

A

Long latent or mildly symptomatic period with progressive LV dilatation-asymptomatic. Symptoms appear after cardiomegaly/CHF and LV dysfunction. Dyspnea and inability to exercise, nocturnal angina (low HR), awareness of heartbeat

42
Q

Symptoms of severe acute aortic regurgitation

A

Sudden collapse with severe dyspnea and hypotension. Pulmonary edema or cardiogenic shock. Sweating, may be stuperous.

43
Q

What are findings in a physical exam of chronic severe AR?

A

Collapsing pulse, wide pulse pressure in BP, diffuse and dynamic apical impulse (wide and diverted to left), soft S1, A2, S3, early diastolic murmur, Austin-Flint murmur.

44
Q

What is the murmur generally heard in aortic regurgitation?

A

Early diastolic, the longer the murmur the more severe the AR.

45
Q

What is the Austin-Flint murmur?

A

Rare, diastolic murmur sounding like mitral stenosis without mitral stenosis. Happens in patients with severe AR because a jet of AR closes the mitral valve early. Middiastolic.

46
Q

What are the clinical signs of acute severe AR?

A

Patient looks gravely ill, tachycardia, peripheral vasoconstriction, pulmonary congestion and edema, low blood pressure, low pulse pressure/low CO, murmur may not be heard or short early diastolic. S1 decreased, S3 and S4.

47
Q

Lab/EKG findings in chronic AR

A

Left axis deviation, signs of volume overload. CXR: cardiomegaly and large LV. Echo shows flow.

48
Q

Can a small level of aortic regurgitation be normal?

A

No, always pathological.

49
Q

Patient management in acute severe AR due to aortic dissection?

A

Immediate surgery, but while waiting give positive inotropic drugs (adrenaline, dopamine) and vasodilators.

50
Q

What is the patient management in acute AR due to endocarditis if stable?

A

Deferred operation and start antibiotics then send for surgery.

51
Q

What is the patient management in acute AR due to endocarditis if unstable?

A

Immediate surgery (positive inotropes in the meantime), then antibiotics.

52
Q

Treatment for chronic AR

A

Just followup for mild/moderate or mildly dilated LV. If severe without symptoms, vasodilators and followup every 3-6 months. If symptomatic/LV dysfunction, mechanical treatment, need to change valves.

53
Q

Surgical treatment-valve replacement for AR-indications

A

If end systolic diameter is >55mm, systolic ejection fraction is

54
Q

What is a composite graft operation?

A

Valve with aortic root both replaced (common in Marfan).

Cardiovascular System (28 decks)

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