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aortic valve (comprehensive) Flashcards

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1
Q

Q: What is the main topic of this lecture?

A

“Aortic Valve Disease”

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2
Q

Q: Who presented the lecture on Aortic Valve Disease?

A

“Dr. Jaber Al Majbery

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3
Q

Q: What are the anatomic components of the aortic root?

A

“The aortic sinuses (or sinuses of Valsalva)

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4
Q

Q: How are the morphology and function of the aortic valve best described?

A

“They are interrelated with the aortic root and best described as a single functional unit.”

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5
Q

Q: How does the diameter of the aortic annulus compare to the sinotubular junction?

A

“The diameter of the aortic annulus is 15% to 20% larger than that of the sinotubular junction.”

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6
Q

Q: How do the lengths of the free margins of the leaflets relate to the sinotubular junction?

A

“The free margins of the leaflets are slightly longer than the diameter of the sinotubular junction.”

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7
Q

Q: What is the morphology of calcific aortic stenosis?

A

“It is congenitally bicuspid

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8
Q

Q: What is the morphology of rheumatic aortic stenosis?

A

“It shows fibrous thickening of a 3-cusp valve

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9
Q

Q: What is the morphology of degenerative aortic stenosis?

A

“It involves diffuse nodular calcification of a 3-cusp valve with no commissural fusion.”

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10
Q

Q: What are the typical age-related causes of aortic stenosis?

A

“Under 70 years: congenital or rheumatic; Over 70 years: degenerative.”

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11
Q

Q: What is the transvalvular gradient in severe AS with normal cardiac output?

A

“It is greater than 50 mmHg.”

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12
Q

Q: What are the consequences of pressure overload in aortic stenosis?

A

“It leads to concentric left ventricular hypertrophy

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13
Q

Q: What are the symptoms of aortic stenosis?

A

“Initially asymptomatic

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14
Q

Q: What are the physical findings in aortic stenosis?

A

“Small volume

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15
Q

Q: What does a softer murmur indicate in aortic stenosis?

A

“It may indicate left ventricular failure.”

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16
Q

Q: What are the ECG findings in aortic stenosis?

A

“Left ventricular hypertrophy (LVH)

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17
Q

Q: What are the CXR findings in aortic stenosis?

A

“Left ventricular prominence with possible cardiomegaly (LV dysfunction)

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18
Q

Q: What imaging modalities are used to assess aortic stenosis?

A

“Echocardiogram with Doppler

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19
Q

Q: What is the prognosis of hemodynamically severe aortic stenosis?

A

“High risk of sudden death

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20
Q

Q: What is the prognosis of mild-to-moderate asymptomatic aortic stenosis?

A

“50% of patients remain event-free for 4 years.”

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21
Q

Q: What is the prognosis of mild-to-moderate symptomatic aortic stenosis?

A

“One-third of patients die within 4 years.”

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22
Q

Q: How does the onset of symptoms in aortic stenosis relate to mortality?

A

“The onset of symptoms correlates with a sharp increase in mortality risk.”

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23
Q

Q: Why does left ventricular hypertrophy occur in aortic stenosis?

A

“To maintain cardiac output through the narrowed valve orifice

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24
Q

Q: What causes exertional syncope in aortic stenosis?

A

“Peripheral vasodilation with fixed cardiac output leads to decreased cerebral perfusion; may also involve tachy- or bradyarrhythmias.”

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25
Q: What is the role of vasodilators in symptomatic aortic stenosis?
"They are potentially dangerous but may be beneficial if used in ICU with close monitoring."
26
Q: What medications can be used for symptomatic AS if CHF is present?
"Diuretics and digoxin."
27
Q: Do medications treat the underlying pathology in AS?
"No
28
Q: What are key points for preventing infective endocarditis in valve disease?
"Maintain good oral hygiene and use aseptic measures during catheterization or invasive procedures to reduce the risk of healthcare-associated endocarditis."
29
Q: What are the types of surgical valve replacement in AS?
"Mechanical valve
30
Q: What are the limitations of balloon valvuloplasty in AS?
"Poor initial success
31
Q: When can balloon valvuloplasty be considered in AS?
"As a bridge to surgery in hemodynamically unstable patients or in those requiring urgent non-cardiac surgery."
32
Q: What is TAVI and when is it used?
"Transcatheter Aortic Valve Implantation is used in symptomatic severe AS
33
Q: How often should asymptomatic severe AS be re-evaluated?
"Every 6 months with monitoring of symptoms
34
Q: What is the follow-up schedule for mild and moderate AS?
"Yearly evaluation; in young patients without significant calcification
35
Q: What mechanisms can lead to aortic regurgitation (AR)?
"Cusp perforation
36
Q: What are the leaflet-related causes of AR?
"Cusp perforation
37
Q: What can cause cusp perforation?
"Infective endocarditis
38
Q: What structural issues lead to cusp prolapse in AR?
"Excess tissue
39
Q: What causes restrictive motion of aortic valve leaflets?
"Fibrous thickening of the cusps."
40
Q: How does sinotubular junction dilatation lead to AR?
"It displaces the commissures outward
41
Q: What are the wall-related abnormalities causing AR?
"Annular dilatation
42
Q: What conditions can cause annular dilatation in AR?
"Marfan syndrome
43
Q: What is the combination that defines aortic root aneurysm?
"Sinotubular junction dilatation along with aneurysm of the sinuses of Valsalva."
44
Q: What congenital conditions can lead to aortic regurgitation?
"Bicuspid valve
45
Q: What valve-related acquired conditions can cause AR?
"Cusp prolapse or shortening with rolled edges
46
Q: What aortic root pathologies can lead to AR?
"Dilation of the sinus of Valsalva
47
Q: What are the symptoms of chronic AR?
"Usually asymptomatic for a long period; later symptoms include exertional dyspnea
48
Q: What are the symptoms of acute AR?
"Sudden severe dyspnea
49
Q: What should be examined in patients with suspected AR?
"Look for signs of underlying diseases such as Marfan's syndrome
50
Q: What are the key peripheral signs of chronic AR?
"Large volume pulse
51
Q: What are the cardiac examination findings in chronic AR?
"Forceful
52
Q: What are the murmur characteristics of AR?
"Early diastolic blowing high-pitched decrescendo murmur at the left 3rd and 4th intercostal spaces parasternally
53
Q: What does the duration of the diastolic murmur in AR correlate with?
"The severity of regurgitation."
54
Q: What is the Austin Flint murmur?
"A mid-diastolic murmur caused by regurgitant blood interfering with the opening of the anterior leaflet of the mitral valve during diastole."
55
Q: What are the clinical signs indicating severe AR?
"Wide pulse pressure
56
Q: What is the natural history of chronic AR?
"Long latent period before cardiac decompensation; sudden death is rare; once LV deterioration starts
57
Q: When should surgery be considered in symptomatic AR?
"Prompt operation is indicated in patients with congestive heart failure
58
Q: What is the recommended management for asymptomatic AR?
"Monitor for left ventricular enlargement or dysfunction using echocardiography; operate at the appropriate time."
59
Q: What is the acute management of severe AR?
"Immediate surgery is the treatment of choice."
60
Q: How should a patient in cardiogenic shock from acute AR be managed?
"Administer IV vasodilators; if AR is severe
61
Q: What is the medical treatment for chronic AR?
"Use calcium channel blockers
62
Q: What is the definitive treatment for symptomatic chronic AR?
"Aortic valve replacement (AVR)."
63
Q: What is the role of infective endocarditis prophylaxis in AR?
"Essential in all patients with valvular heart disease to reduce healthcare-associated infections; includes good oral hygiene and aseptic technique."
64
Q: What is the follow-up schedule for mild-to-moderate AR?
"Yearly clinical review and echocardiography every 2 years."
65
Q: What is the follow-up plan for severe AR with normal LV function?
"Follow-up at 6 months after initial assessment."
66
Q: What are the indications for surgery in symptomatic aortic regurgitation?
"Presence of dyspnea (NYHA class II
67
Q: When is surgery indicated in asymptomatic AR with preserved LV function?
"If there is severe LV dilatation: end-diastolic dimension >70 mm or end-systolic dimension >50 mm (or >25 mm/m² BSA)."
68
Q: What are surgical indications in patients undergoing other cardiac procedures?
"Patients having CABG or surgery on the ascending aorta or another valve should also have AVR if indicated."
69
Q: What are the threshold aortic diameters for surgery in aortic root disease?
"More than 45 mm in Marfan syndrome
70
Q: What additional anatomical considerations guide surgery for aortic root?
"Shape and thickness of ascending aorta and other parts of the aorta should be considered."
71
Q: What is the basic anatomical layout of the aortic root and valve area?
"It includes the aortic wall
72
Q: What are the three levels where aortic stenosis can occur?
"Supravalvular
73
Q: What syndrome is associated with supravalvular aortic stenosis?
"Williams syndrome."
74
Q: What are features of Williams syndrome?
"Elfin-like facies
75
Q: What are examples of subvalvular causes of aortic stenosis?
"Discrete fibromuscular ring (10% of congenital AS)
76
Q: What are subvalvular anomalies linked with AV canal defects?
"Parachute mitral valve deformity with fused papillary muscles."
77
Q: What is an anacrotic pulse and what does it indicate?
"A low volume
78
Q: What is pulsus alternans and when is it seen?
"Alternating strong and weak pulse; seen in severe left ventricular dysfunction."
79
Q: What is a classic auscultatory finding of aortic stenosis murmur?
"Ejection systolic murmur heard at the base
80
Q: What is the significance of a soft or inaudible A2 in AS?
"It may indicate a calcified and immobile valve."
81
Q: What is the Austin Flint murmur and in which condition does it occur?
"A mid-diastolic murmur due to regurgitant aortic blood interfering with mitral valve opening; occurs in severe AR."
82
Q: What is the typical progression of valvular aortic stenosis in adults according to postmortem data?
"There is a latent period followed by symptom onset
83
Q: What defines severe aortic stenosis?
"Aortic valve area <1 cm² or <0.6 cm²/m² body surface area."
84
Q: What is the significance of an ejection fraction <50% in AS?
"It indicates reduced left ventricular function and influences management decisions."
85
Q: What is the clinical approach for physically active patients with AS?
"Perform an exercise test; if abnormal
86
Q: What does a marked increase in peak jet velocity over 1 year suggest in AS?
"It may indicate rapid progression and worsening of stenosis."
87
Q: What pulse characteristics are associated with AR?
"Collapsing (water hammer) pulse
88
Q: What causes a hyperdynamic apex in AR?
"Large stroke volume due to volume overload of the left ventricle."
89
Q: What is Hill's sign in AR?
"A difference in systolic pressure >60 mmHg between popliteal and brachial arteries."
90
Q: What is the typical murmur of AR?
"A full-length
91
Q: What happens to S2 in severe AR?
"A2 may be inaudible and P2 may be obscured."
92
Q: When does the Austin Flint murmur disappear?
"In severe AR with premature mitral valve closure."
93
Q: What are surgical indications in AR with left ventricular dilation?
"End-diastolic dimension >70 mm or end-systolic dimension >50 mm or >25 mm/m² BSA."
94
Q: What factors determine surgical threshold in patients with aortic root disease?
"Maximal aortic diameter (>45 mm in Marfan’s
95
Q: When can surgery on the ascending aorta be combined with AVR?
"If surgery on the aortic valve is already indicated
96
Q: What change during follow-up might prompt surgery for AR?
"Significant changes in symptoms
97
Q: What is the purpose of classifying levels of aortic stenosis?
"To identify whether the stenosis is supravalvular
98
Q: What anatomical structure lies between the aortic valve and the sinotubular junction?
"The interleaflet triangle."
99
Q: What is the 'ventriculo-arterial junction'?
"The junction between the left ventricle and the aorta
100
Q: What does the basal ring represent anatomically?
"It is a fibrous ring at the base of the aortic valve within the left ventricle."
101
Q: What is the relationship between the sinotubular junction and the ascending aorta?
"The sinotubular junction marks the transition from the aortic root to the ascending aorta."
102
Q: In which direction is the apex beat displaced in AR?
"Downward and laterally
103
Q: What effect does large stroke volume have on the pulse?
"It creates a bounding
104
Q: What murmur timing and location are characteristic for AR?
"An early diastolic murmur at the left 3rd–4th intercostal space
105
Q: What is the significance of murmur duration in AR?
"The longer the murmur
106
Q: What happens to S1 and S2 in aortic stenosis with calcification?
"S1 is soft; A2 (part of S2) may become inaudible if the valve is heavily calcified."
107
Q: Why might the second heart sound (S2) be reversed in AS?
"Due to prolonged left ventricular ejection time."
108
Q: What is a 'boot-shaped' heart on CXR typically associated with?
"Left ventricular hypertrophy or dysfunction as seen in severe aortic valve disease."
109
Q: What does a paradoxically split S2 indicate?
"It may indicate delayed aortic valve closure
110
Q: What is the role of echocardiography in aortic valve disease?
"It is essential for evaluating valve anatomy
111
Q: What type of follow-up is required after AVR or in severe valve disease?
"Regular clinical and echocardiographic follow-up to monitor symptoms

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