Mixed Aortic Valve Disease

Question 1

What are the examination findings/signs of mixed aortic valve disease?

Answer 1

1. Pulsus bisiferiens (2 strong systolic peaks separated by midsystolic dip)
2. Determining AS or AR is dominant
   - AS dominant: small volume pulse, heaving undeviated apex beat, reduced pulse pressure
   - AR dominant: large volume bounding pulse, thrusting deviated apex beat, increased pulse pressure
3. Murmur
   - ESM
   - EDM
   - Austin Flint murmur - rergurgitant jet passing through the aortic valve and hitting the adjacent mitral valve leaflet

Question 2

What are the causes of mixed aortic valve disease?

Answer 2

1. Rheumatic heart disease
2. Congenital bicuspid valve

Question 3

What is the treatment for mixed aortic valve disease?

Answer 3

Depends on symptoms
If asymptomatic, treat medically (beta blockers for rate control, ACEi for vasodilation, diuretics)

If symptomatic, generally surgical treatment with TAVI or open valve replacement

Question 4

Differentiating predominant AS vs predominant AR

Answer 4

Note: pulse character may be bisiferens

If unable to differentiate dominance, suggest for TTE, cardiac catheterisation or aortogram for assessment

Question 5

Describe this heart sound

Answer 5

Both ESM and EDM - mixed aortic valve disease of AS and AR