Aortic Valve Disease

Front 1

aortic valve anatomy

Back 1

3 cusps- leaflets
Non coronary cusp/LCC- LCA arises/RCC- RCA arises
mercedes benz sign

Front 2

aortic valve sclerosis

Back 2

aortic valve thickening without obstruction
25-30% >65, >80 about 1/2 have this on assessment of aortic valve disease
marker for CVD
structurally abn but hemodynamically not causing problems

Front 3

Clinical findings

Back 3

short midsystolic ejection murmur, not loud,
localized to aortic area
carotid pulse normal volume and contour
s2 normal

Front 4

echo features

Back 4

increased echogenicity of leaflets, without commusural thickening, no significant obstruction to outflow

Front 5

aortic valve sclerosis prognosis

Back 5

can progress to clinically significant stenosis in one of 8 and severe in 1/64
marker for widespread atherosclerotic disease

Front 6

management of Ascelorosis

Back 6

control of Cardiac risk factors
follow up - to see if they progress

Front 7

aortic valve stenosis

Back 7

restricted CO secondary to valve not opening adequately
some hemodynamic consequences

Front 8

causes of AS

Back 8

congenitally abn valve, bicuspid valve
unicuspid or quad valve
degeneric or calcific valve - from a sclerosis progressio
Rheumatic valve disease
rare causes: metabolic disease, collagen vascular- SLE, paget's disease,

Front 9

bicuspid AV

Back 9

common 2% of population
3:1 male to female
coexisting coarctation of aorta in 6%- decreased perfusion to periphery and leads to HTN
associated to aortic root abn- leading to dilation and dissection
biscupid is the most common

Front 10

rheumatic aortic valve i

Back 10

involves more of the commissures not the cusps - thats why orifice is small

Front 11

incidence of differen etiology

Back 11

world wide rheumatic disease- most common
100% affects mitral- if no mitral valve involvement- not rheumatic
in dev- degenerative and bicuspid
bicuspid-more seen in younger
degenerative- still could be bicuspid but usually older

Front 12

pathyphys consequences of AS

Back 12

obstruction to aortic outflow- gradual
concentric LVH- to maintain wall stress- to pump blood through to maintain CO
over time LV compliance will decrease- LVED pressure increases -systolic dysfunction - LV dilates, and significant LHF- CO drops even further

Front 13

AS symptoms

Back 13

dyspnea on exertion and decreased exercise tolerance
dizziness, syncope
angina

Front 14

Dyspnea

Back 14

related to LVH, impaired relaxation, increased LV filling pressure, increased LA pressure, increased Pulmonary pressure - interstitial edema

Front 15

decreased exercise intolerance

Back 15

inability of LV to increase CO required with exercise due to fixed obstruction
exercising muscles need more blood

Front 16

dizziness/syncope

Back 16

peripheral vasodilation to increase blood pressure to exercising muscle- so get vasodilation but no increase in CO - so get hypotensive

Front 17

ventricular arrhythmias

Back 17

calcifications can extend to conducting system

Front 18

angina

Back 18

supply demand mismatch- dont have CAD, still get angina- even with normal LV blood supply, hypertrophy is such that outstrips normal coronary blood supply
also compression on intramural cornary arteries due to prolonged contraction and impaired relaxation

Front 19

physical exam AS

Back 19

decreased volume, slow upstroke central pulses, (parvus et tardus) low volume - low CO, dleayed upstroke- takes LV long time to overcome obstruction and reach peak pressure
check brachial and carotid pulses -for volume and contour
large apex- LVH
thrill in aortic area- significant AS- turbulent blood flow through small orifice
S2 single - ventricle takes longer - A component is delayed and merged with P2- also softer b/c valve not very mobile
S4- atria contracting into a stiffered ventricle
systolic ejection murmur- loudest in the aortic area heard all over precordium -

Front 20

how to tell severity of AS based on murmur

Back 20

way to tell severity- where it peaks in systole
early- ventricle doesnt have trouble overcoming obtruction
late- ventricle having hard time overcoming obstruction

Front 21

investigations AS

Back 21

ECG: LVH
CXR: AV calcification, LVH, dilated aortic root
Echo: gold -
visual appearance of valve- bicuspid? thickening commisural? leaflets?
valve areas
LV thickness size

Front 22

grading AS

Back 22

valve areas:
normal 3- 4 cm2
mild 1.5-2
moderate 1-1.5
severe<1

Front 23

tx

Back 23

no medical tx
valve replacement only option:
deciding when the valve needs to be replaced imp

Front 24

indication for surgery

Back 24

any symptoms- indication that heart is not liking this
SOB, angina, dzziness, exercise intolerance

in the absence of symptoms- LV pumping function decline- ie EF low <50

prophylaxis for endocarditis no longer recommended

Front 25

surgical options

Back 25

percutaneous valve replacements- for those people that cant undergo surgery

Front 26

Aortic Regurgitation

Back 26

can be acute or chronic
same as insufficient
caused by inadequate closure of leaflets- abn structure of dilation of aortic valve root or anullus

Front 27

acute severe Regurg

Back 27

medical emerg- b/c LV unable to adapt to regurgitant flow- rapid heart failure and cardiogenic shock

Front 28

etiology severe acute regurg

Back 28

endocarditis- due to valve destruction
aortic dissection-
Trauma- decelaration injuries

Front 29

clinical features aortic dissection

Back 29

sudden collapse with preceding sudden knifelike mid capular back pain

Front 30

endocarditis

Back 30

fever, embolic events, sick with septic symptoms

Front 31

physical exam AR

Back 31

hypotensive
low pulse volume
if dissection- inequality of upper limb pulses
soft or absent S1- mitral valve closes early b/c inc LV diastolic pressure
acute pulmonary HTN- loud P2
acute heart failure- S3
diastolic murmur is short or absent- very little difference between two areas -

Front 32

definite diagnostic procedure

Back 32

echo can visualize abn valve - size
regurg
and lV function size

Front 33

tx of ASAR

Back 33

emergency Aortic valve replacement

Front 34

chronic AR etiology

Back 34

abnormal aortic valve :
RF, bicuspid or degenerative valve- same as AS
also dilatation of aortic root
bicuspid valve commonly associated with dilatation of the aorta
connective tissue disorders- marfan- tends to dilate more than usual under increased pressure

Front 35

pathyphys of AR

Back 35

increased LV SV - more blood is leaking back- by about 50%- increased LV volume, inc wall stress, LVH

CO inc due to inc LV stroke volume
LV compensates by Dilating so LVEDP remains normal

Front 36

chronic AR sx

Back 36

may be asymptomatic for decades
palpitation-
decreased exercise capacity, HF symptoms
dev of HF: dyspnea, orthopnea, PND
angina uncommon- coronary arteries dilated- blood flow occurs during diastole

Front 37

physical exam chronic AR

Back 37

high volume pulse with a sudden collapse - water hammer pulse
wide pulse pressure- big systolic pressure- very low diastolic pressure
large and displaced apex due to LV dilatation and hypertrophy
A2 soft and absent - due to AV leaflets not coapting
diastolic decrescendo murmur- along left or R sternal border, high pitched blowing. longer the murmur, the more severe it is, except for Acute severe
systolic ejection murmur due to high cardiac output
austin flint murmur -

Front 38

austin flint murmur

Back 38

AR regurg - goes to ward mitral valve- and produces a murmur close to one of mitral stenosis

Front 39

murmur in AR

Back 39

high pitched blowing decrescendo diastolic murmur at LSB

Front 40

unusual findings in chronic severe AR

Back 40

Demussett's - head bob when heart beats
mueller's sign- pulsation of uvula
beckers' sign- pulsation of retinal arteries and pupils
lighthouse sign- blanching and blushing of forehead

Front 41

chronic AR echo

Back 41

identify valve pathology
assess aortic root and LV size and function
assess severity of AR

Front 42

natural hx of AR

Back 42

long latent period - decades
decomp: when LV systolic function fails
progressive LV dilatation occurs

initially reversible- but overtime irreversible

Front 43

asymptomatic MR

Back 43

no support for medical tx
abx prophylaxis for endocarditis no longer reccommeded
valve replacement EF<50
also presence of symptoms
decline in LV function

Front 44

symptomatic AR

Back 44

valve replace
ACE inhibitors, diuretics - short term

Front 45

Mixed AV disease

Back 45

usually abnormal valve not root problems
sx same as AS and AR
physical findings- some may cancel each otehr out- pulse volume and contour normal
AR: inc CO AS reducing CO- moderate of both - may not indicate one or the other
do echo
indications for surgery - symptoms or decline in LV function