Aortic Stenosis

Question 1

Signs

Answer 1

Inspection
- JVP raised (HF)
- visible apex heave (LVH)
Palpating
- Slow rise pulse
- Heaving apex (LVH)
- systolic click/thrill aortic area
Auscultation
- ESM radiating to carotids
- reduced/absent 2nd heart sound
(ES click after 1st HS indicates pliable (likely bicuspid I’m young)
-4th HS if LVH and ventricle stuff
- bibasal creps/ peripheral oedema

Question 2

Signs of severity

Answer 2

1. Character of arterial pulse
2. Presence or absence of 2nd heart sound
3. Presence or absence of signs of heart failure

Question 3

Aetiology

Answer 3

Calcific degenerative
Congenital (bicuspid)
Rheumatic (rare in west)

Question 4

Differential Diagnoses

Answer 4

1. Aortic Sclerosis - crossover with mild AS
2. PS - normal 2nd HS, louder P area louder on inspiration
3. VSD - heard all over praecordium, maximal LSE. More likely thrill (maladie de roger)
4. HOCM - jerky pulse, quieter if crouching, no ejection click, normal second HS, younger patient
5. Subaortic membrane (rare) - no click, normal 2nd HS (membrane (usually muscular) just below aortic valve
6. Supra-valvular obstruction (extremely rare) - as above (characteristic of Williams syndrome - Elfin faces)

Question 5

Investigations

Answer 5

1. Echo - confirms diagnosis. Valve area preferred method (but more subject to error) for grading severity as pressure gradient influenced by ventricular function. Severe AS <0.6cm/m2
2. Stress Echo - if poor LV function and AS. Can suggest if valve replacement will help symptoms or if all due to LVSD
3. Angio before surgery
4. ECG obviously

Question 6

Echo grading

Answer 6

Mild - >1.5cm2 area or <20mmHg mean valve gradient
Moderate - 1-1.5cm2 or 20-40mmHg
Severe - <1cm or >40mmHg

Question 7

Management

Answer 7

1. 6-12 monthly follow up if asymptomatic
2. Surgery
3. TAVI
4. BAV

Question 8

When to consider surgery

Answer 8

1. If symptomatic
If not then maybe if:
2. Mean gradient >40 AND
- EF <45%
- abnormal response to exercise (hypotension)
- ventricular tachycardia
- LVH > 15mm
- valve area <0.6

Question 9

Common complications

Answer 9

1. Endocarditis
2. Heart failure
3. Heart block (calcific ring invasion of his-purkinje system
4. Embolic events

Question 10

Associated conditions

Answer 10

1. Coarctation of aorta (check for radio-femoral delay)
2. Other valve disease (particularly mitral in rheumatic disease)
3. Angiodysplasia of colon and anaemia (heyde syndrome (also acquired coagulopathy))