Aortic Stenosis By Sr

Front 1

Name 3 causes of Aortic Stenosis. Which are most common?

Back 1

Degenerative or senile; mean age 65 to 70 (most common)
Congenital (BAV) (most common cause < 50 years of age)
Rhematic fever (post-inflammatory) (9%)

Front 2

What is Aortic valve sclerosis?

Back 2

Aortic valve thickening (sclerosis) without stenosis common in elderly adults.

Front 3

AV sclerosis signs?

Back 3

Irregular leaflet thickening and focal increased echogenicity (calcification) are the hallmarks of the condition. Focal areas of thickening are typically seen on the aortic side of the valve in the center of the valve cusp, rather than at the leaflet edges, often initially involving the noncoronary cusp.
Leaflet excursion is not impaired and the commissures are not fused. Peak continuous wave Doppler flow velocities across the valve are normal or only minimally elevated (<2.0 m/sec).

Front 4

What is Aortic valve stenosis?

Back 4

Abnormal narrowing of the Aortic valve orifice. Obstructs flow between LV and Aorta.

Front 5

Name 4 signs/symptoms of AS. What is the most common?

Back 5

Dyspnea on exertion (most common)
Heart failure - Ischemic chest pain
Agina Pectoris
Syncope (effort)

Front 6

Name 4 complications of AS.

Back 6

• LV response to chronic pressure overload is concentric LVH. (without chamber dilation)
• Increased LV edp
• Increased LAE leading to Pulmonary Hypertension and Rt heart failure
• LV systolic dysfunction (later stages) due to increased afterload. This is reversible with Valve Replacement.

Front 7

What is the left ventricular response to the chronic pressure overload of AS?

Back 7

LV Pressure overload = LVH

Front 8

AS pressure overload does not cause the LV chamber to dilate. If the patient has AS and LVE is seen, what is most likely the cause of the LV chamber enlargement?

Back 8

??? Mitral Stenosis ???

Front 9

Describe the murmur of AS and where to hear it best.

Back 9

Harsh crescendo-decrescendo systolic ejection best heard at 2 RIS. May radiate into Carotid arteries
Early systolic ejection click (Bicuspid Ao)

Front 10

M-mode findings in AS.

Back 10

Decreased AO cusp separation (< 1.2 cm)
Thickened Aortic valve leaflets (pg 30 Arizona)
Eccentric lines of closure (Bicuspid Ao)
Leaflet thickening, commissural fusion, systolic doming with coexisting MV disease suggests Rheumatic origin
LVH-suggests significant AS
LAE- caused by decreased LV compliance and MR
MAC- 50%

Front 11

2D findings in AS List 4

Back 11

Bicuspid Valve- systolic doming in PLA view
Post stenotic dilatation of AO Root
Increased density and decreased separation of AO Valve leaflets (< 1.2 cm)
Concentric LVH- due to chronic pressure overload
PSA-Ao best view to assess valve calcification Classified: Mild, Moderate, Severe
LAE - due to pressure overload and decreased LV compliance
Decreased LV function in severe AS due to increased afterload. Reversible with AVR.
LVE- if AI present * MAC in 50% of patients

Front 12

Color Flow:in AS

Back 12

Can help identify location of jet for Doppler cursor placement.

Front 13

Doppler in AS

Back 13

Ao flow: Use CW: High > 1.7 m/sec velocity = stenosis
Ao velocity profile:
Normal: peaks earlier in systole
AS: later the peak = more severe the stenosis
Best views

Front 14

4 types of AS

Back 14

•Acquired bicuspid aortic valve with secondary calcification. At the center of the conjoined cusp (lower center) are elements of two preexisting cusps, now fused.
•Congenital bicuspid valve. The characteristic raphe of the congenital bicuspid aortic valve appears at the lower portion of the figure.
•Senile type. None of the commissures is fused, but there is a major intrinsic calcification of the three cusps.
•Unicuspid, unicommissural congenital aortic stenosis with secondary calcification.
•Calcific (Senile, Degenerative) elderly (60+), calcific process usually seen on Aortic side of leaflets
•RHD: thick, fused commissures with varying degrees of calcifications.
•Doming cusps. Usually w/Mitral RHD
•Congenital: Bicuspid Ao Valve
•Unicuspid:
•Quadricuspid

Front 15

Describe the M-mode findings of a Bicuspid Aortic valve.

Back 15

•M-Mode - Eccentric lines of closure in diastole

Front 16

Describe the 2D findings of a Bicuspid Aortic valve.

Back 16

•Normal AV is Y shaped when closed in diastole, systolic bowing or doming into Aorta looks “dome-like”
•Commissures located at 10, 2, and 6 o’clock normally
•Any deviance from this: suspect BAV
•BAV in systole will appear as football or fish-mouth
•Raphe (where cusps failed to separate)
•PSA-Ao: Must look in systole when Ao Valve is open.
oA “raphe” can mislead you to think there are 3 leaflets in diastole.

Front 17

What view and in what time of the cardiac cycle is best for distinguishing a BAV from a normal AV?

Back 17

Systole

Front 18

What can contribute to misidentifying a Bicuspid valve?

Back 18

•A “raphe” can mislead you to think there are 3 leaflets in diastole.