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Valvular Heart Disease II: The Aortic Valve

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Title: Valvular Heart Disease II: The Aortic Valve


1
Valvular Heart Disease IIThe Aortic Valve
  • Laura Wexler, M.D.
  • 475-6383
  • wexlerl_at_ucmail.uc.edu

2
Reference Sources for Valvular Heart Disease
  • Reading Harrison, 14th Edition p 1311-1323
  • Computer
  • Umedic Aortic stenosis, aortic regurgitation,
    mitral stenosis, mitral regurgitation
  • Instructional Programs
  • Heart Sounds and Murmurs

3
  • Case
  • An active 75 yo farmer comes to your office
    after experiencing a fainting spell while baling
    hay. The episode occurred without warning and he
    had no symptoms following the episode. However,
    on close questioning he admits to some
    breathlessness and vague chest heaviness with his
    usual heavy exertion over the past few months. He
    has been healthy all his life, doesnt smoke and
    has not seen a doctor in 30 years. He served in
    the army in 1942 no abnormalities were reported
    during his induction physical.

4
Physical Exam
  • Robust looking older man.
  • BP 135/90 P 68 bpm, regular RR-12
    T-98.6? F
  • JVP 6 cm with normal a and v waves
  • Carotids Difficult to palpate, delayed
    upstroke
  • Lungs Clear
  • Heart Palpation Palpable thrill over the
    mid LSB. PMI 5 ICS, 2 cm lateral to the MCL.
    Palpable presystolic impulse followed by a
    sustained ventricular lift.
  • Auscultation Loud S4. S1 is normal. A
    single S2 (P2) is heard at the upper left sternal
    border but no A2 is heard at the lower left
    sternal border. There is a 4/6 systolic ejection
    murmur (crescendo-decrescendo) heard best at the
    R 2nd interspace that radiates widely to the LSB,
    and to the neck. No diastolic murmurs.
  • Abdomen and extremities are unremarkable.

5
Aortic Stenosis
6
Aortic Stenosis Etiology
Norma Burns
  • Congenital bicuspid aortic valve
  • Rheumatic aortic valve disease
  • Calcific (senile) aortic stenosis

7
Pathophysiology of Aortic Stenosis
  • Left ventricular outflow obstruction
  • LV systolic pressure aortic pressure
  • Concentric left ventricular hypertrophy
  • Sustains high LV pressures
  • Normalizes wall stress (radius x pressure/wall
    thickness)
  • Eventually results in impaired LV diastolic
    compliance
  • LA hypertrophy and enlargement
  • Severe stenosis Limits ability to increase
    stroke volume on demand
  • Critical aortic stenosis fixed cardiac output

8
Key Physical Findings in SevereAortic Stenosis
  • Carotid impulse parvus et tardus
  • JVP Prominent a wave
  • Heart Systolic thrill
  • Palpable presystolic impulse (S4)
  • Sustained apical systolic impulse S4
  • Coarse late peaking systolic ejection murmur
    (may radiate to neck and/or LSB)
  • Attenuated/absent aortic component of S2

9
Natural History of Aortic Stenosis
  • Long asymptomatic latent period
  • Cardinal symptoms of severe aortic stenosis
  • Dyspnea
  • Angina
  • Syncope
  • Sudden death
  • Left ventricular dilatation and contractile
    failure
  • Endocarditis
  • Arrhythmias
  • Ventricular tachycardia
  • Conduction system disease
  • Atrial fibrillation

10
Natural History of AS
11
Mechanisms of Dyspnea inAortic Stenosis
  • LVH ? diastolic dysfunction
  • Progressive LV dilation and contractile failure ?
    systolic dysfunction

12
Mechanisms of Anginal Chest Pain inAortic
Stenosis
  • Increased wall stress ? increased myocardial O2
    demand, exceeds ability to coronary flow to meet
    demand
  • Associated coronary artery disease

13
Mechanisms of Syncope in Aortic Stenosis
  • Fixed cardiac output Vasodilation (exercise,
    vagal stimulation, drug induced), inability to
    augment CO, drop in cerebral perfusion pressure.
  • Heart block Ca deposits in aortic ring
    encroach upon conduction tissue
  • Ventricular arrhythmias (LVH, ischemia)

14
Diagnostic Studies in Aortic Stenosis
  • ECG LVH with repolarization changes strain
    pattern
  • Chest X-Ray Aortic root dilation
    (aortic valve Ca)
  • Echo Aortic valve thickening and restricted
    motion
  • Doppler Gradient across aortic valve and aortic
    valve area can be estimated from increased flow
    velocity across aortic valve
  • Cath Measure gradient across aortic valve and
    calculate valve area

15
Aortic Stenosis
16
Treatment of Aortic Stenosis
  • Mild to moderate asymptomatic aortic stenosis
  • Close follow up History and physical exam,
    serial echocardiograms
  • Endocarditis prophylaxis
  • Severe, symptomatic aortic stenosis (1 year
    survival 57)
  • Aortic valve replacement with either mechanical
    or bioprosthetic valve
  • - Ten year survival 75
  • - Complications of prosthetic heart valves
    infection, thromboembolism, mechanical
    failure
  • Severe, symptomatic aortic stenosis NOT
    surgically treatable
  • Palliative option aortic balloon valvuloplasty

17
  • CASE
  • A 52 yo salesman is referred to you for
    evaluation of a heart murmur. He had applied for
    a pilots license and was denied because of the
    murmur. He is asymptomatic and physically
    active. He denies chest pain, dyspnea or dizzy
    spells and gives no history of a murmur being
    mentioned during his last physical exam five
    years ago. He has no family history of heart
    disease. He has never had high blood pressure or
    diabetes, doesnt smoke, and takes no
    medications. A lipid profile done five years
    ago was reported to be OK.

18
Physical Exam
  • BP - 145/45 P - 78 reg RR
    - 12 Temp98.6F
  • Carotids Very brisk with sharp collapse
  • JVP 5 with normal a and v waves
  • Lungs Clear
  • Heart Palpation PMI is enlarged (4fb), in the
    anterior axillary line
  • Auscultation S1 normal, S2 soft. A 2/6 early
    peaking systolic ejection murmur at the upper
    RSB and a 3/6 holodiastolic blowing murmur,
    heard best at the lower LSB when you ask the
    patient to hold his breath in expiration and
    lean forward. There is a different 2/6
    low-pitched diastolic murmur at the apex.
  • Pulses are all very prominent and brisk audible
    pulse over
  • the femoral arteries

19
Additional Testing
  • ECG LVH with massive voltage in the lateral
    precordial leads (V4-V6)
  • Chest X-Ray Large heart, predominant left
    ventricular enlargement. No congestive heart
    failure.
  • Echo Marked left ventricular dilation, estimated
    EF 65. The end diastolic dimension is 65 mm
    and the end diastolic dimension is 55 mm.
    Aortic valve bicuspid and thickened.
  • Doppler Severe aortic regurgitation. The aorta
    is slightly enlarged (4.2 mm).


20
Major Causes of Aortic Regurgitation
  • Leaflet Dysfunction Aortic Root Dilation
  • Rheumatic fever Systemic hypertension
  • Endocarditis Dissecting aneurysm
  • Trauma Aortitis (syphilis)
  • Bicuspid aortic valve Reiters syndrome
  • Rheumatoid arthritis Ankylosing spondylitis
  • Myxomatous degeneration Ehlers-Danlos
  • Ankylosing spondylitis Osteogenesis imperfecta
  • Marfans syndrome Pseudoxanthoma elasticum
  • Fenfluramine-phentermine Marfans syndrome
  • Annulo-aortic ectasia

21
Aortic regurgitation
22
Physical Findings in Aortic Regurgitation
  • Wide pulse pressure
  • Bounding pulses
  • Soft aortic second sound (A2)
  • Early diastolic murmur (blowing) immediately
    after A2
  • Upper RSB with root dilation
  • Mid to lower LSB with leaflet dysfunction
  • Systolic murmur at base (similar to aortic
    stenosis)
  • Austin Flint murmur mid to late diastolic
    rumble at apex

23
Some Really Neat Physical Findings in Severe
Chronic Aortic Regurgitation
  • deMussets sign Head bob with each systolic
    pulsation
  • Corriganss pulses Pistol shot pulses over
    femoral artery
  • Muellers sign Pulsation of the uvula
  • Duroziezs sign Systolic/diastolic bruit over
    femoral artery
  • Quinckes pulses Capillary pulsations seen in
    the nailbeds
  • Beckers sign Pulsation of retinal arteries and
    pupils
  • Hills sign Popliteal BP exceeds brachial BP by
    60 mmHg

24
Acute vs. chronic aortic regurgitation
25
Pathophysiology of Chronic Aortic Regurgitation
  • Slowly progressive diastolic volume overload
  • Augmented stroke volume with rapid runoff
  • Increased systolic pressure with low
  • diastolic pressure wide pulse pressure
  • Progressive left ventricular dilation, some
    hypertrophy
  • Increased diastolic compliance with maintenance
    of normal diastolic pressures initially
  • Late systolic failure with reduced ejection
    fraction and CHF

26
Acute Aortic Regurgitation
  • Sudden diastolic volume overload without LV
    dilation
  • - Acute elevation in left ventricular
    diastolic pressure? pulmonary edema
  • - Acute LV systolic failure ? hypotension
  • Provide inotropic support, vasodilator therapy if
    tolerated, urgent valve replacement.

27
Natural History of Chronic Aortic Regurgitation
  • Long asymptomatic phase may be decades long.
  • Left ventricular systolic dysfunction ( decline
    in EF)
    NOTE!! LV dysfunction may
    occur in the absence of symptoms
  • Symptoms associated with LV dysfunction
  • - Exercise intolerance
  • - Dyspnea on exertion
  • Angina (rare)
  • Sudden death (rare)

28
Natural history of aortic regurgitation
29
Factors Influencing Severity ofAortic
Regurgitation
  • Size of regurgitant orifice
  • Gradient across aortic valve in diastole (i.e.
    worse AR with high diastolic BP)
  • Duration of diastole

30
Management of Chronic Aortic Regurgitation
  • Close follow up of left ventricular size and
    function with serial echocardiograms (Every few
    years with mild AR, every 6-12 months with severe
    AR)
  • Endocarditis prophylaxis
  • Medical therapy
  • Vasodilator therapy reduces blood
    pressure?reduces
    regurgitant volume
  • Delays need for aortic valve
    replacement
  • Digoxin (enhance systolic function)
  • Diuretics (reduce LA pressure)
  • Do NOT slow heart rate!
  • Aortic valve replacement with mechanical or
    bioprosthetic valve

31
Criteria for Aortic Valve Replacement in Chronic
Aortic Regurgitation
  • Symptoms
  • Congestive heart failure
  • Declining exercise tolerance on exercise
    testing
  • Angina
  • Anatomy, regardless of symptoms
  • Left ventricular dysfunction EF
  • Progressive left ventricular dilation or
    decline in EF on serial studies
  • Severe dilation (echo)
  • - Left ventricular diastolic dimension 75
    mm
  • - Left ventricular systolic dimension 55
    mm
  • Aortic root dimension 50 mm

32
Right Sided Valve DiseaseRead Harrison, 14th
Edition Pages 1322-1323
  • Tricuspid stenosis
  • Tricuspid regurgitation
  • Pulmonic stenosis
  • Pulmonic regurgitation
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