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34 Cards in this Set
- Front
- Back
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What is afterload the sum of? (3)
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arterial blood pressure + aortic compliance + obstructuve lesions
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What is the normal diameter of an aortic valve?
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3cm
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What are 2 major categories of aortic pathology?
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Bicuspid aorta
Degenerative aorta (calcific, rheumatic) |
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What are three structural complications that occur due to obstructed outflow in AS?
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Pressure hypertrophy (concentric)
Diastolic dysfunction (due to hypertrophy) Myocardial Ischemia |
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Put the following in order of speed of progression of aortic calcification from youngest to oldest:
Congenital bicuspid aortic valves Acquired aortic stenosis Congenital aortic stenosis Tricuspid aortic valves |
Congenital aortic stenosis>acquired aortic stenosis>congenital bicuspid aortic valves>tricuspid aortic valves
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What are the clinical manifestations of AS (in order of improtance)?
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Angina
Syncope (esp. effort related) Dyspnea (heart failure) |
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What factors decrease O2 supply to myocardium in AS? (2)
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Endocardial compression
CAD (if present) |
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What factors increase O2 demand in the myocardium in AS? (3)
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LV hypertrophy
Increased O2 uptake Increased wall stress |
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What are causes of syncope in AS? (2)
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Exertion (exercise, emotion, eating) - due to inability to raise cardiac output
Arrythmia |
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What is the pathophysiological cause of dyspnea in AS?
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Heart failure due to diastolic dysfunction of the LV
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What is the cause of sudden death in patients with AS?
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Arrhythmia
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What is the natural history of AS?
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Asymptomatic for a long period then rapid degeneration after onset of symptoms (angina>syncope>dyspnea)
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What type of murmer do you hear in AS and where is it located?
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Crescendo-decrescendo systolic murmer heard best at upper right sternal border (ejection murmer)
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What adventitious sounds do you hear on cardiac exam of AS (besides murmer)?
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S4
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What is the carotid pulse like in AS?
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Delayed upstroke and decreased volume
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What pathologies are people with bicuspid aortic valve prone to? (6)
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AS, AR, ascending aortic aneurysm, aortic dissection, aortic valve endocarditis, aortic coarctation (rare)
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How do you diagnosis AS (tests and their findings)?
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ECG: LA enlargement, LV hypertrophy
CXR: post-stenotic aortic dilation, aortic Ca++ ECHO: thickened and restricted leaflets, decreased valve area, increased pressure gradient Cardiac cathaterization: gradient Stress Test: for prognosis not diagnosis |
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What are mild, moderate and severe values for valve area and mean gradient in AS?
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mild = 1-1.5cm, <20mmHg
moderate = 0.7-1cm, 20-40mmHg severe = <0.7cm, >40mmHg |
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How do you treat mild/moderate asymptomatic AS?
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Close follow-up
Educate about endocarditis risk Treat atherosclerotic risk factors |
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How do you treat sever AS that is symptomatic? Asymptomatic?
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Valve replacement, same for asymptomatic
DO NOT GIVE afterload-reducing drugs |
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What are etiological classifications for AR? (3)
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Diseased valve cusps (calcific, degenerative, bicuspid, rheumatic)
Diseased aorta (aortopathies, marfan syndrom, syphilis, etc.) Acute Pathology (aortic dissection, trauma, endocarditis, prosthetic valve failure) |
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What pathological abnormalities are seen in acute AR?
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Volume overload in LV that is transmitted back causing heart failure
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What pathological abnormalities are seen in chronic AR?
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Huge LV (eccentric hypertrophy)
Large stroke volume and pulse pressure Normal ejecting fraction if stable or reduced ejection fraction if LV becomes dysfunctional |
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What is the natural history of AR?
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Very long asymptomatic phase with remodelling
Insidious and irreversible onset of ventricular dysfunction/reduced ejection fraction Symptoms late (heart failure) |
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What are the clinical manifestations of AR?
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Palpitations (due to large stroke volume)
Heart failure Angina and syncope (rare) |
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What type of murmer do you hear in AR and where is it located?
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High pitched early diastolic murmer heard from right base to apex
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What findings (besides murmer) do you find on cardiac physical exam in AR?
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S3, wide pulse pressure, bounding pulses, hyperdynamic precordium, dispaced apex
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What diagnostic tests can use and what are the findings for AR?
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ECG - LVH
CXR - cardiomegaly ECHO - regurgitation |
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How do you manage AR (non-surgical)?
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Vasodilators - nifedipine, ACE-inhibitors, hydralazine
Diuretics Educate re: endocarditis risk Avoid bradycardia Monitor LV size and function by ECHO |
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What are indications for surgery in AR (definite, very probable, probable)?
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Definite - symptomatic with normal ejection fraction OR asymptomatic with mildely decreased ejection fraction
Very probable - asymptomatic with normal ejection fraction but severe LVH Probable - Severe left ventricular diastolic dysfunction (heart failure) |
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What are 2 major errors when managing AR?
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Failed to monitor asymptomatic ventricular remodelling
Did not replace valve soon enough once symptoms developed |
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How do you insert a new aortic valve (what is the procedure called)?
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Percutaneous Valve Intervention
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What are late complications of aortic valve replacement? (4)
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Thromboembolism
Mechanical valve thrombosis (need to be on anti-coagulants) Heart block Prosthetic valve endocarditis |
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What is 1) the main problem in the LV 2) the main remodelling and 3) the indications for surgery in AS and AR
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AS - pressure overload, concentric hypertrophy, symptoms
AR - volume overload, eccentric hypertrophy, adverse ventricular remodelling |
