Aortic Valve Diseases PDF

Aortic Valve disease By Dr Mahmoud Tantawy Lecturer of Cardiology MD. Cardiology, FACC, FESC, HMD  Discus Discuss the common etiologies of aortic valve stenosis and s regurgitation. Recog Recognize the signs and sy...

Aortic Valve disease By Dr Mahmoud Tantawy Lecturer of Cardiology MD. Cardiology, FACC, FESC, HMD  Discus Discuss the common etiologies of aortic valve stenosis and s regurgitation. Recog Recognize the signs and symptoms of nize severe AV stenosis and regurgitation Goals and Objectives Be able to quickly identify and treat Be acute aortic regurgitation Identif Identify patients who should be referred for surgical replacement of y their valves Overview Aortic Aortic Regurgitati Stenosis on Acute and Chronic  AS & AR Pathophysiol Physical Etiology ogy Exam Natural Testing Treatment History  Aortic Stenosis  Normal Aortic Valve Area: 3-4 cm2 Aortic Symptoms: Occur Stenosis when valve area is 1/4th Overview of normal area. : Types: Supravalv Subvalvula Valvular ular r  Etiology of Aortic Stenosis Degenerative/ Congenital Rheumatic Calcific Patients under Patients over 70: >50% have a 70: 50% due to congenital cause degenerative  A pressure gradient develops between the left ventricle and the aorta. (increased Pathophys afterload) iology of LV function initially Aortic maintained by Stenosis compensatory pressure hypertrophy When compensatory mechanisms exhausted, LV function declines.  Syncope: (exertional) Angina: (increased myocardial oxygen demand; Presenta demand/supply tion of mismatch) Aortic Dyspnea: on exertion Stenosis due to heart failure (systolic and diastolic) Sudden death  Slow rising carotid pulse (pulsus tardus) & decreased pulse amplitude (pulsus parvus) Physical Heart sounds- Findings soft and split second heart in Aortic sound, S4 gallop due to LVH. Stenosis Systolic Loudness ejection murmur- does NOT cresendo- decrescendo tell you character. This peaks later as anything the severity of about the stenosis increases. severity Natural History 8% in 10 years Mild AS to 22% in 22 years Severe AS: The onset of symptoms is a poor 38% in 25 years prognostic indicator.  Evaluation of AS Echocardiography is the most valuable test for diagnosis, quantification and follow-up of patients with AS. Left ventricular size and function: Two measurements LVH, Dilation, and EF obtained are: Doppler derived gradient and valve area (AVA) Evaluati Cardiac catheterization: Should only be done for a direct measurement if symptom on of AS severity and echo severity don’t match OR prior to replacement when replacement is planned.  Medical - limited role General- IE since AS is a prophylaxis in dental mechanical problem. procedures with a Vasodilators are prosthetic AV or relatively history of contraindicated in endocarditis. severe AS Manage Aortic Balloon Surgical ment of Valvotomy- shows little benefit. Replacement: Definitive treatment AS TAVI.  Mild: Every 5 years Echo Moderate: Every 2 Surveilla years nce Severe: Every 6 months to 1 year  Simplified Indications for Surgery in Aortic Stenosis Any SYMPTOMATIC patient with Any patient severe AS Any patient with undergoing CABG (includes decreasing EF with moderate or symptoms with severe AS exercise)  Summary Look for the Echocardiogra Disease of signs on m to assess aging physical exam severity Asymptomatic: Symptomatic: Medical AoV management replacement and (even in elderly surveillance and CHF)  Aortic Regurgit ation  Definition: Leakage Aortic of blood into LV Regurgita during diastole due to tion ineffective coaptation Overview of the aortic cusps Etiology of Acute AR Endocarditis Aortic Dissection Physical Findings: Wide pulse pressure Diastolic murmur Pulmonary edema  True Surgical Emergency: Positive inotrope: (eg, dopamine, dobutamine) Treatmen Vasodilators: (eg, t of nitroprusside) Acute AR Avoid beta-blockers Do not even consider a balloon pump Etiology Bicuspid aortic valve of Rheumatic Chronic Infective endocarditis AR Combined pressure AND volume overload Compensatory Mechanisms: LV dilation, LVH. Progressive dilation leads to heart failure Pathophysiology of AR  Natural History of AR Asymptomatic until 4th or 5th decade Rate of Progression: 4-6% per year Progressive - Dyspnea: exertional, orthopnea, and paroxsymal nocturnal dyspnea Symptoms Nocturnal angina: due to slowing of heart rate and reduction of diastolic blood pressure include: Palpitations: due to increased force of contraction  Physical Exam findings of AR Wide pulse pressure: most sensitive Hyperdynamic and displaced apical impulse Auscultation- Diastolic blowing murmur at the left sternal border Austin flint murmur (apex): Regurgitant jet impinges on anterior MVL causing it to vibrate Systolic ejection murmur: due to increased flow across the aortic valve  CXR: enlarged cardiac silhouette and aortic root enlargement ECHO: Evaluation of the AV and aortic root with The measurements of LV Evaluatio dimensions and function n of AR (cornerstone for decision making and follow up evaluation) Aortography: Used to confirm the severity of disease Management of AR Medical: Vasodilators General: IE (ACEI’s), prophylaxis in Nifedipine dental procedures improve stroke with a prosthetic volume and AV or history of reduce endocarditis. regurgitation only if pt symptomatic or HTN. Serial Surgical Echocardiogram Treatment: s: to monitor Definitive Tx progression.  ANY Symptoms Simplified at rest or exercise Indication s for Asymptomatic Surgical treatment if: Treatment EF drops below of AR 50% or LV becomes dilated THANK YOU