Aortic Valve Disease

Question 1

What are the 3 main causes/etiologies of aortic stenosis?

Answer 1

Congenital valve malformation i.e. Bicuspid aortic valve
Rheumatic
“Senile” calcific disease

Question 2

What happens to the valve to cause stenosis in bicuspid aortic valve?

Answer 2

Wear and tear on the valve causes calcium to build up and inhibit opening

Question 3

What happens to the valve to cause stenosis in rheumatic disease?

Answer 3

Fuses the comissures - causing scarring

Question 4

What happens to the valve to cause stenosis in “senile” calcific disease?

Answer 4

Valve was normal but wear and tear caused build up of calcium

Question 5

What factors does aortic stenosis have in common with coronary atherosclerosis?

Answer 5

Both more common in men, elderly, and patient with hypercholesterolemia
Derived in part from inflammatory process

Question 6

Which etiology does aortic stenosis before the age of 60 indicate?

Answer 6

Bicuspid valve

Question 7

Which etiology does aortic stenosis after the age of 60 indicate?

Answer 7

Probably “senile” calcific valve

Question 8

What happens to the LV when there is aortic stenosis?

Answer 8

Aortic stenosis –> increased pressure in LV –> LV concentric hypertrophy –> increased LV stiffness

Question 9

What symptoms make up the clinical triad of aortic stenosis?

Answer 9

Congestive heart failure
Angina Pectoris
Syncope (effort related)

Question 10

What are physical diagnosis signs of aortic stenosis?

Answer 10

Murmur
Ejection click
Carotid artery pulsation
S4 sound (atrial gallop)

Question 11

Describe the murmur heard in aortic stenosis

Answer 11

Crescendo-decrescendo between S1 and S2

Question 12

Describe the ejection click heard in aortic stenosis

Answer 12

High frequency sound hear just after S1

Occurs at the time of aortic valve opening

Question 13

Describe the carotid artery pulsation felt in aortic stenosis

Answer 13

Because of obstruction, upstroke of carotid may be slowed and can feel a slow rise in carotid on palpation

If stroke volume is low (later in disease), can palpate flow turbulence, felt as a vibration

Pulsus parvus et tardus (small and late pulse)

Question 14

Describe the S4 sound heard in aortic stenosis

Answer 14

Tap right before S1 (presystolic)

Reflects a stiff left ventricle that you can feel at apex

Question 15

What etiology of aortic stenosis does the ejection click suggest?

Answer 15

Bicuspid valve

Question 16

What is a good sentence to remember that S4 goes with aortic stenosis?

Answer 16

“A stiff wall”

Where S4 is the “A”

Question 17

What can you have the patient do to be able to hear the S4 better?

Answer 17

Have patient do sit ups (exercise) or have them squeeze your finger
This will acutely increase BP

Question 18

What are clues of aortic stenosis that can be seen on echo?

Answer 18

Anatomy, detect calcification, evaluate opening of valve

Quantitate pressure gradient across the AV and calculate aortic valve area

Question 19

Which patients should be given antibiotic prophylaxis before dental work?

Answer 19

Patients with:
Prosthetic valves
Previous endocarditis
Specific congenital heart disease

Question 20

What are the two types of replacement valves?

Answer 20

Mechanical

Tissue

Question 21

What type of valve should younger patients receive?

Answer 21

Mechanical

Question 22

What type of valve should older patients receive?

Answer 22

Tissue

Question 23

What are the advantages and disadvantages of mechanical valves?

Answer 23

Advantage - long lasting

Disadvantage - need anticoagulation

Question 24

What are the advantages and disadvantages of tissue valves?

Answer 24

Advantage - do not need anticoagulation

Disadvantage - degenerates over time

Question 25

What are possible complications of prosthetic heart valves?

Answer 25

``` Thromboembolism Bleeding (secondary to anticoagulation) Valve dysfunction Valve regurgitation Endocarditis ```

Question 26

What other aortic issue is bicuspid aortic valve associated with?

Answer 26

Aortic dilations, aneurysms and dissections | Due to accelerated degeneration process that results in structural weakness of wall

Question 27

What are the two major etiologies that lead to aortic regurgitation?

Answer 27

Abnormalities of valve leaflet | Dilatation of aortic root

Question 28

What happens to the LV when there is chronicaortic regurgitation?

Answer 28

Aortic valve leaflets cannot coapt --> backward runoff --> volume overload of the LV --> LV dilatation --> increased LV diastolic volume --> wall stress --> formation of new sarcomeres "eccentric hypertrophy"

Question 29

What occurs to the systemic diastolic pressure and systemic systolic pressure in chronic aortic regurgitation?

Answer 29

Decreased systemic diastolic pressure - aortic valve cannot maintain pressure in aorta in diastole Increased systemic systolic pressure - large volume of blood goes backwards, increasing the SV from LV into aorta Causes WIDE PULSE PRESSURE

Question 30

What is concentric hypertrophy and is it seen in aortic stenosis or aortic regurgitation?

Answer 30

Pressure overload leads to fattening of myocytes and sarcomeres added in parallel, causing LV hypertrophy Aortic stenosis

Question 31

What is eccentric hypertrophy and is it seen in aortic stenosis or aortic regurgitation?

Answer 31

Volume overload leads to stretching of the myocytes and sarcomeres added in series, causing LV dilation Aortic regurgitation

Question 32

What are symptoms of aortic regurgitation?

Answer 32

Congestive heart failure Occasionally angina Wide pulse pressure

Question 33

What are physical signs of aortic regurgitation?

Answer 33

Wide pulse pressure (i.e. 200/40) Cardiomegaly (LV dilated) Murmur

Question 34

Describe the murmur heard in aortic regurgitation?

Answer 34

Early diastolic high-pitched blowing murmur (heard after S2)

Question 35

In what location and what position (of the patient) is the aortic regurgitation murmur best heard?

Answer 35

``` Location = sternal border Position = leaning forward ```

Question 36

What are some of the peripheral findings caused by the wide pulse pressure in aortic regurgitation?

Answer 36

Synchronous head bob (de Musset's sign) Uvula pulsing Capillaries of finger Carotid double beating

Question 37

What are clues of aortic regurgitation that can be seen on echo?

Answer 37

Aortic regurgitation flow | Determine LV function

Question 38

What are the causes of acute aortic regurgitation?

Answer 38

Secondary to trauma, endocarditis, aortic dissection Severe = surgical emergency

Question 39

Why is acute aortic regurgitation so dangerous?

Answer 39

LV does not have time to dilate and acute increase in LV pressure can be abruptly reflected back to the lungs, causing acute pulmonary edema and death

Question 40

How do the physical findings of acute aortic regurgitation differ from those of chronic aortic regurgitation?

Answer 40

Signs of chronic AR are often absent in acute AR - NO cardiomegaly (LV hasn't had time to dilate) - NO wide pulse pressure - NO long diastolic blowing murmur

Question 41

Why is there no widened pulse pressure in acute aortic regurgitation?

Answer 41

Regurgitant volume into a non-dilated LV will cause LV diastolic pressure to rise Diastolic pressure in aorta can only drop as low as diastolic pressure in LV - so diastolic pressure in aorta will not be low LV cannot respond with increased stroke volume - so systolic pressure in aorta may not be elevated Thus, wide pulse pressure is gone

Question 42

Why is there no murmur in acute aortic regurgitation?

Answer 42

Early equilibration of aortic and LV diastolic pressures shortens the murmur