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Updated: Aug 4 2022

Aortic Stenosis

Images echo..jpg,_gross_pathology_20g0014_lores.jpg
  • Snapshot
    • A 74-year-old man reports a 3-month history of intermittent chest pain, syncopal episodes, and dyspnea on exertion. He has a long-standing history of coronary artery disease and hypertension. Physical exam reveals a systolic crescendo-decrescendo murmur, heard best at the heart base and radiates to the carotids. He is sent for further evaluation with an echocardiogram.
  • Introduction
    • Clinical definition
      • narrowing of the aortic valve
    • Associated conditions
      • hemolytic anemia
  • Etiology
    • Age-related dystrophic calcification of normal (tricuspid) aortic valve in older patients
    • Calcification of bicuspid aortic valve in younger patients
    • Pathogenesis
      • atherosclerosis can lead to plaque formation and calcium deposits on the aortic valve
      • aortic stenosis results in ↑ left heart pressure → left ventricular hypertrophy (LVH)
      • LVH and stiff, noncompliant walls result in ↑ oxygen demand and clinically manifests as angina
      • over time, aortic stenosis results in ↓ blood flow to the vertebral, basilar, and carotid arteries, resulting clinically in syncope
  • Epidemiology
    • Demographics
      • bicuspid aortic valve calcification
        • presents at a younger age
      • tricuspid aortic valve calcification
        • > 65 years of age
    • Risk factors
      • hypertension
      • coronary artery disease
      • rheumatic heart disease
  • Presentation
    • Symptoms
      • heart failure
      • SAD
        • Angina or chest pain (most common)
        • Dyspnea
    • Physical exam
      • systolic ejection murmur
        • heard best at heart base
        • may have ejection click
        • radiates to carotid arteries
        • crescendo-decrescendo murmur
        • decreases with standing, Valsalva, or handgrip
        • increases with amyl nitrate, squat, or leg raise
        • single, soft S2
          • suggestive of severe aortic stenosis
      • S4 heart sound
        • from stiff or hypertrophic ventricle
      • paradoxical splitting of S2
        • heard on expiration rather than inspiration
      • pulsus parvus et tardus
        • weak pulses with a delayed peak
  • Imaging
    • Radiography
      • indication
        • for all patients
      • findings
        • cardiomegaly
        • calcification
        • pulmonary congestion
    • Echocardiography
      • indications
        • for all patients
        • diagnostic test
      • views
        • transthoracic echocardiogram (TTE) initially
        • transesophageal echocardiogram (TEE) is more accurate
      • findings
        • thick aortic valve leaflets
        • aortic valve anatomic abnormalities
        • LVH
  • Studies
    • Electrocardiogram (ECG)
      • indications
        • for all patients
      • findings
        • LVH
    • Left heart catheterization
      • indications
        • most accurate diagnostic test
        • to assess pressure gradient across the valve
        • only indicated to confirm the diagnosis if echocardiography is unclear
      • findings
        • elevated pressure gradient (> 30 mmHg)
  • Differential
    • Hypertrophic cardiomyopathy
      • distinguishing factor
        • normal aortic valve on echo and murmur that does not radiate to the carotids
  • Diagnosis
    • Making the diagnosis
      • based on clinical presentation and echocardiogram
  • Treatment
    • Medical
      • diuretics
        • indication
          • best initial therapy for all patients with pulmonary congestion
    • Operative
      • aortic valve replacement
        • indication
          • definitive treatment
          • if patients are symptomatic
          • if aortic valve area is < 0.8 cm2 (normal 2.5-3 cm2)
          • if ejection fraction < 50%
        • modalities
          • bioprosthetic valves require more frequent replacement but do not require anticoagulation
          • mechanical valves are not replaced as often but must be treated with anticoagulation
      • balloon valvuloplasty
        • indication
          • in patients too ill for surgery
  • Complications
    • Arrhythmia
    • Heart failure
    • Endocarditis
  • Prognosis
    • Often asymptomatic
    • Once symptomatic, most patients require aortic valve replacement
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