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Questions and Answers
Which sign is indicative of chronic aortic regurgitation, characterized by an exaggerated upstroke and fall of the arterial pulse?
What is a common investigation used to assess the severity of aortic regurgitation?
In acute aortic regurgitation, which condition is typically presented?
What treatment is indicated for chronic aortic regurgitation to control blood pressure?
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What characteristic sound is associated with the murmur of aortic regurgitation?
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Which treatment modality for aortic regurgitation is considered interventional?
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The presence of a diminished S2 heart sound in aortic regurgitation is most often associated with what condition?
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Which symptom is unlikely to be experienced in chronic aortic regurgitation due to increased stroke volume?
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What is the primary symptom associated with severe aortic stenosis?
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Which of the following best describes the pathophysiological progression of aortic stenosis?
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What auscultatory finding is commonly associated with severe aortic stenosis?
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Which classification type describes the narrowing of the aortic valve opening itself?
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What is the most common cause of aortic stenosis in older individuals from western countries?
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Which symptom may occur due to diminished cerebral perfusion in severe aortic stenosis?
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What characteristic change is often observed in the pulse of a patient with severe aortic stenosis?
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Which of the following best describes a common cause of aortic stenosis in younger individuals in developing countries?
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Study Notes
Aortic Valve Anatomy
- Three cusps attached to the proximal aorta (aortic root)
- No subvalvular apparatus
- Opens during systole (ejection phase) allowing blood flow from the left ventricle to the aorta
- Closes during diastole (producing S2) to prevent backward flow from the aorta to the left ventricle
Aortic Valve Pathology
- Stenosis: narrowing of the aortic valve opening
- Regurgitation: backward flow of blood from the aorta to the left ventricle due to improper closure of aortic valve cusps or failure of cusps coaptation during diastole
Aortic Stenosis
-
Classification
- Valvular AS: Narrowing of the aortic valve opening
- Subvalvular AS: Stenosis below the aortic valve in the left ventricular outflow tract (membrane or ridge)
- Supravalvular AS: Stenosis above the aortic valve in the aorta (narrowing in the ascending aorta)
-
Causes
- Congenital: Bicuspid aortic valve, Subvalvular AS, Supravalvular AS
- Degenerative: Old age, Western countries
- Rheumatic: Young age, Developing countries
-
Pathology
- Thickening, fibrosis, calcification of the valve causing narrowing of the opening
-
Pathophysiology
- Progressive aortic valve narrowing leads to progressive left ventricular hypertrophy (LVH), increased left ventricular systolic pressure with increased myocardial oxygen demand, this leads to myocardial ischemia and left ventricular failure (pulmonary congestion)
Aortic Stenosis Presentation
- History
- Typically asymptomatic until valvular stenosis is severe
- The hallmark of AS is the classical triad of exertional dyspnea, angina, and syncope (or near-syncope)
- Exertional dyspnea is the most common symptom associated with severe AS
- Angina without significant obstructive coronary artery disease is caused by subendocardial ischemia due to increased total oxygen demand secondary to LVH
- Exertional syncope (or near syncope) occurs due to diminished cerebral perfusion secondary to low cardiac output
- Symptoms may not develop simultaneously, only one of the three may be present
- Physical Examination
- Hallmarks of severe AS on physical examination include:
- Pulse: Reduction in the amplitude and delay of the carotid upstrokes (“parvus et tardus”).
- Apical impulse: Shifted downwards, outwards, heaving character, localized (LV apex).
- Cardiac auscultation
- Diminution or entire loss of the second heart sound (↓S2)
- An opening ejection click in patients with a bicuspid valve
- Ejection systolic crescendo-decrescendo murmur (radiates to the carotids, sometimes associated with a thrill. Radiation may also occur across the precordium and to the apex (Gallavardin phenomenon) associated with a musical, high frequency quality)
- Hallmarks of severe AS on physical examination include:
- Investigations
- Echocardiography: Assess severity of AS, LV function
- CXR: Lung congestion
- ECG: LVH
Aortic Stenosis Treatment
- Prophylaxis against infective endocarditis, secondary prevention of rheumatic activity
- Medical: Diuretics for HF symptoms
- Interventional: Transcatheter aortic valve implantation (TAVI)
- Surgical: Aortic valve replacement either by mechanical or tissue prosthesis
Aortic Regurgitation
- Presentation
- Acute AR: Presented with acute pulmonary edema, or cardiogenic shock
Chronic Aortic Regurgitation
- History
- Symptoms are related to exaggerated cardiac output with increased stroke volume, including a sense of pounding in the chest
- Palpitations
- Dyspnea
- Chest pain
- Symptoms are related to exaggerated cardiac output with increased stroke volume, including a sense of pounding in the chest
- Physical Examination
- Blood pressure: High systolic BP, Low DBP, Wide pulse pressure
- Pulse:
- Water hammer: Characterized by exaggerated upstroke and fall of the arterial pulse, notable in the carotid pulse.
- Apical impulse: Shifted downwards, outwards, hyperdynamic character (LV apex)
- Cardiac auscultation
- Diminution of the second heart sound (↓S2) with thickened calcific valve and accentuated S2 with dilated aortic root
- The murmur of AR:
- High-pitched (“blowing”) in quality.
- Radiation: Along the left sternal border and is best heard with the patient sitting up and leaning forward after full expiration. If the murmur radiates along the right sternal border, it is suggestive of a dilated aortic root.
- Ejection systolic murmur (Functional AS; caused by ↑ systolic forward flow).
- Very significant AR may be accompanied by a low pitched late mitral diastolic rumble (= MS; the “Austin-Flint” murmur) due to improper opening of the mitral valve by the aortic regurgitant jet.
- Investigations
- Echocardiography: Assess severity of AR, LV function, define the cause of AR
- CXR: Lung congestion
Aortic Regurgitation Treatment
- Prophylaxis against infective endocarditis, secondary prevention of rheumatic activity
- Medical: Diuretics for HF symptoms, Dilators. Good blood pressure control (afterload reduction) with calcium channel blockers and vasodilators (ACE inhibitors)
- Surgical:
- For Acute AR: Treat the cause, hemodynamic support, AV replacement
- For Chronic AR:
- AV replacement (mechanical or biological prosthesis) ± Aortic root replacement
- AV repair
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Description
Test your knowledge on the anatomy and pathology of the aortic valve. This quiz covers components such as the cusps, functions during systole and diastole, and conditions like stenosis and regurgitation. Assess your understanding of aortic stenosis classifications and causes.
