Aortic Stenosis-Insufficiency

Question 1

What are the 4 AORTIC ROOT anatomic components:

Answer 1

• The aortic annulus or aortoventricular junction
• The leaflets
• The aortic sinuses or sinuses of Valsalva
• The sinotubular junction

Question 2

The morphologic characteristics and function of the aortic valve are interrelated to the aortic root and are best described as a single functional unit. The diameter of the aortic annulus is

Answer 2

15% to 20% larger than the diameter of the sinotubular junction.

Question 3

Severe AS & normal cardiao output =

Answer 3

transvalvar gradient >50mmHg

Question 4

normal aortic valve area =

Answer 4

3.0 to 4.0 cm2

Question 5

MILD Aortic Stenosis
Mean Gradient :
Aortic Valve Area:

Answer 5

Mean Gradient : < 25

Aortic Valve Area: > 1.5

Question 6

Moderate Aortic Stenosis
Mean Gradient :
Aortic Valve Area:

Answer 6

Mean Gradient : 25 - 40

Aortic Valve Area: 1.0 - 1.5

Question 7

Severe Aortic Stenosis
Mean Gradient :
Aortic Valve Area:

Answer 7

Mean Gradient : > 40

Aortic Valve Area: < 1.0

Question 8

Critical Aortic Stenosis
Mean Gradient :
Aortic Valve Area:

Answer 8

Mean Gradient : > 70

Aortic Valve Area: < 0.6

Question 9

AS: Clinical Picture Symptoms

Answer 9

• Asymptomatic
• Syncope
• Angina
• CHF
• Sudden Death

Question 10

HAEMODYNAMICALLY SEVERE

symptomatic or asymptomatic

Answer 10

• Sudden death risk high

- Immediate operation is indicated

Question 11

HAEMODYNAMICALLY MILD – MODERATE (asymptomatic)

Answer 11

• 50% event free for 4 years

- Operation is not urgent, but patients should be followed carefully as the disease advances rapidly

Question 12

HAEMODYNAMICALLY MILD – MODERATE (SYMPTOMATIC)

Answer 12

• One-third will die within 4 years

- Prompt operation is indicated

Question 13

Natural History Progression average for Aortic Stenosis ?

Answer 13

0.1 cm2 per year

Question 14

Management of Aortic Stenosis for an Asymptomatic patient (Mild - Moderate) ?

Answer 14

• Medical follow up
• Regular ECHO
• Avoid strenuous exercise
• Endocarditis prophylaxis
• ? Role for statins
• Progress ~0.1cm2 per year

Question 15

Management of Aortic Stenosis for an Symptomatic patient with the following symptoms?

• Angina, syncope, failure
• Moderate AS + CAD
• Reduced BP on exercise
• Severe AS & reduced LV function

Answer 15

AVR

Question 16

Infective endocarditis, Trauma, or

Iatrogenic cause leads to _________, which causes Aortic Regurgitation due to abnormalities of the leaflets.

Answer 16

Cusp Perforation

Question 17

Excess of tissue, Disrupted commissure, and Commissural malposition leads to _________ which causes Aortic Regurgitation due to abnormalities of the leaflets.

Answer 17

Cusp prolapse

Question 18

Fibrous thickening can lead to ________ which causes Aortic Regurgitation due to abnormalities of the leaflets.

Answer 18

Restrictive motion

Question 19

4 Congenital Defects that lead to Aortic Regurgitation

Answer 19

• Bicuspid valve
• Supra-valvar stenosis
• Supra-cristal VSD and right coronary prolapse
• Sinus of Valsalva aneurysm

Question 20

5 valve acquired diseases which lead to Cusp prolapse or cicatricial shortening of cusps with rolled edges which eventually lead to Aortic Regurgitaion ?

Answer 20

• Rheumatic fever
• Infective endocarditis
• Rheumatoid disease
• SLE
• Hurler’s syndrome

Question 21

6 Aortic Root acquired diseases which lead to Dilation of sinus aorta and failure of coaptation of cusps which eventually lead to Aortic Regurgitaion ?

Answer 21

• Dissection
• Syphilis
• Cystic medial necrosis e.g Marfans – annulo-aortic ectasia
• Arthritides with aortitis e.g. Ankylosing spondylitis
• Hypertension
• Trauma

Question 22

Medical MANAGEMENT of AR ?

Answer 22

• Calcium channel blocker
• Regular ECHO
• Avoid isometric exercise
• Endocarditis prophylaxis
• Monitor for symptoms
• Protracted course

Question 23

Management of AR if patient is symptomatic ?

Answer 23

AVR

Question 24

AR patient is asymptomatic if ?

Answer 24

• LVESD > 50-55mm
• LVEDD > 70-75mm
• LVEF < 55%

Question 25

AVR very effective treatment even in patients over age

Answer 25

70 or 80

Question 26

Even the best patients over age 80 have

Answer 26

reduced reserve

Question 27

9 Increased risks during AVR if

Answer 27

• Emergency
• NYHA Class III – IV
• > 65 years old
• Severe AS AVA70, LVEDP>20
• Impaired LV systolic function
• Need for other procedure (CABG)
• Renal dysfunction
• Small BSA
• Redo operation

Question 28

Post op complications for AVR ?

Answer 28

• Operative mortality: ~ 5%
• Complete heart block
• Ischemic heart disease (6 months from coronary ostial
  stenosis)
• CVA 3 – 5%

Question 29

What is the percentage of 5 year survival prognosis for patients with normal LV function who underwent an AVR ?

Answer 29

96%