Aortic Stenosis - Lecture Notes PDF

AORTIC Stenosis Pr M. NAZZI Sub-Module: Cardiology - Lecture 4 Semester S5 www.um6ss.ma Academic year: 2024-2025 1 Learning objectives Define AORTIC stenosis (AS) Know the Physio...

AORTIC Stenosis Pr M. NAZZI Sub-Module: Cardiology - Lecture 4 Semester S5 www.um6ss.ma Academic year: 2024-2025 1 Learning objectives Define AORTIC stenosis (AS) Know the Physiopathology of Aortic stenosis Defien the etiologies Symtomatic Triad of AS How to diagnose Aortic stenosis (clinical features, ECG, Chest X-ray, Echocardiography) Define different therapeutic strategies and indications FACULTY OF MEDICINE – UM6SS – CASABLANCA 2 2 DEFINTION Aortic stenosis (AS) is narrowing of the aortic valve, obstructing blood flow from the left ventricle to the ascending aorta during systole. More Common after 70 yo Normal aortic area: 3cm 2 SEVERE IF < 1 cm2 FACULTY OF MEDICINE – UM6SS – CASABLANCA 3 3 EPIDEMIOLOGY MOST COMMON MEAN AGE: 64 +/- 14 DEGENERATIVE +++ Male predominance FACULTY OF MEDICINE – UM6SS – CASABLANCA 4 4 ANATOMY FACULTY OF MEDICINE – UM6SS – CASABLANCA 5 4 ANATOMY FACULTY OF MEDICINE – UM6SS – CASABLANCA 6 4 ANATOMY FACULTY OF MEDICINE – UM6SS – CASABLANCA 7 5 ETIOLOGY FACULTY OF MEDICINE – UM6SS – CASABLANCA 8 6 PATHOPHYSIOLOGY AORTIC STENOSIS FACULTY OF MEDICINE – UM6SS – CASABLANCA 9 7 CLINICAL FEATURES: Asymptomatic if moderate Aortic stenosis Classical Presentation : Triad symptom Dyspnea : 50 % Systolic dysfunction Diastolic dysfunction Angina : 30% Functional in 75% Organic in 25% Syncope or lipothymia: 15% Brain anoxia Arrhythmias and cardiac conduction disturbances. FACULTY OF MEDICINE – UM6SS – CASABLANCA 10 8 CLINICAL FEATURES: Inspection : There are no visible signs of aortic stenosis Palpable signs include carotid and peripheral pulses that are reduced in amplitude and slow rising (pulsus parvus et tardus) and an apical sustained impulse. systolic thrill, corresponding with the murmur of AS and felt best at the left upper sternal border FACULTY OF MEDICINE – UM6SS – CASABLANCA 11  8. CLINICAL FEATURES: Auscultation: The hallmark finding is a crescendo-decrescendo ejection murmur, heard best with the diaphragm of the stethoscope at the right and left upper sternal borders when a patient who is sitting upright leans forward. The murmur typically radiates to the right clavicle and both carotid arteries FACULTY OF MEDICINE – UM6SS – CASABLANCA 12 9. ECG : LV HYPEROPHYTROPHY FACULTY OF MEDICINE – UM6SS – CASABLANCA 13 10. Chest x-Ray : Normal. Dilatation of Aorta FACULTY OF MEDICINE – UM6SS – CASABLANCA 14 Chest x-Ray : Normal. Dilatation of Aorta FACULTY OF MEDICINE – UM6SS – CASABLANCA 15 11. ECHOCARDIOAPHY DIAGNOSIS: Aortic opening and morphology SEVERITY: GRADIENT AND AORTIC AREA ETIOLOGY REPERCUSSION : LVH, SYSTOLIC AND DIASTOLIC LV FUNCTION. ASSOCIATED Lesions Ascending aorta 16 ECHOCARAPHY (QUANTIFICATION) AORTIC AREA MEAN GRADIENT LV-AO > 40 mmHg AO ARE < 1 cm2 SEVERE AO STENOSIS 17 SEVERITY OF AORTIC STENOSIS FACULTY OF MEDICINE – UM6SS – CASABLANCA 18  ECHOCARDIRAPHY (LV RERCUSSION) VH ENLARGEMENT OF THE ASC AORTA YSTOLIC LV FUNCTION PULMONARY PRESSURE DIASTOLIC LV FUNVCTION 19 12. OTHER WORK OUT EXPLORATIONS) TRANSESOPHAGEAL ECHOCARDIOGRAPHY CT SCAN: calcium score , Before TAVI BNP TREDMILL exercise TEST Dobutamin Echo coronaro-angiography before surgery in old patients > 50yo or in case of risk factors. 20 RIGHT HEART IMPACT Tricuspid Regurgitation Vena Cava enlargement Pulmonary Hypertension 21 TRANS ESOPHAGEAL ECHOCARDIOGRAPHY AORTIC AREA BY PLANIMERY 22  13. OUTCOME : Progressive disease Regular Follow-up Bad Prognosis if symptoms: life expectancy: 5 years if Angina 5 years if Syncope 2 years if dyspnea 6 months if Heart failure FACULTY OF MEDICINE – UM6SS – CASABLANCA 23 13. OUTCOME AND ETIOLOGY Congenital Ao stenosis: steady for 2-3 decades before worsening Rhematic stenosis progress slowly Monckeberg disease mild progress Quick worsening if extensive calcifications or in dialysis patients. Asymptomatic: watchful Follow-up every 6 month 24 14. COMPLICATIONS: Arrhyhmias Cardiac Conduction disturbances LEFT HEART FAILURE Systemic cardiac embolism Infective endocarditis Sudden death 25  15. MANAGEMENT: Hygienic measures : Avoid intensive exercise No Medical Therapy except ARF prophylaxis: Benzathin penicillin/15 days if rheumatic etiology. Diuretics if Heart failure Vasodilatators nitrates are prohibited Surgery is the only therapeutic option if symtomatic. FACULTY OF MEDICINE – UM6SS – CASABLANCA 26  MANAGEMENT: A. Surgical Valve Replacement: - Bioprosthesis: - Elderly - No anticoagulants - Degeneartion or calcification over time 10- 15 y - Mechanical Prosthesis - Young - Long life expectancy FACULTY OF MEDICINE – UM6SS – CASABLANCA 27  SURGICAL MANAGEMENT: B. TRANSCATHETER AORTIC VALVE IMPLANTATION (TAVI) Indications: - INOPERATIVE PATIENTS WITH SURGERY HIGH RISK FACULTY OF MEDICINE – UM6SS – CASABLANCA 28 (TAVI) FACULTY OF MEDICINE – UM6SS – CASABLANCA 29 INDICATIONS OF SURGERY: SYMTOMATIC SEVERE AORTIC STENOSIS: SURGERY AS SOON AS POSSIBLE ASYMPTOMATIC BUT SEVERE: SURGERY IS RECOMMANDED IF EXERCISE TREST ABNORMALITIES: Symptoms Low Blood pressure during the test Ventricular arrhythmias desire for pregnancy: LV dysfunction Quick progression of the gradient 30 Preventive treatment: Primary prophylaxis secondary prevention 31  Summary Most common etiologies of Aortic Stenosis are: congenital bicuspid valve, idiopathic degenerative sclerosis with calcification, and rheumatic fever. Untreated AS progresses to become symptomatic with one or more of the classic triad of syncope, angina, and exertional dyspnea; heart failure and arrhythmias may develop within the risk of Sudden death. A crescendo-decrescendo ejection murmur is characteristic. Diagnosis is by physical examination and echocardiography. Asymptomatic AS in adults usually requires no treatment. 54 FACULTY OF MEDICINE – UM6SS – CASABLANCA