Valvular Heart Disease: Aortic valve disease

1. Parker Ward, MD Valvular Heart Disease:Aortic valve disease

2. An asymptomatic 48 yo man comes to your office for routine eval. He is physically active and jogs five miles 3 times weekly. He has no chest pain or syncope. He says a heart murmur was heard ten yrs ago during a physical exam but no f/u eval was done. BP is 130/70. A grade 3/6 crescendo-decrescendo murmur is heard at the LUSB with a preserved second heart sound. A grade 2/6 diastolic murmur is heard at the left lower sternal border. The remainder of the exam in normal. Echo shows a bicuspid aortic valve. Mean aortic gradient is calculated to be 35mm Hg, and aortic regurg (3+) is noted. LVEF is 70% and left ventricular internal dimensions are normal. In addition to advice regarding SBE prophylaxis, mgmt of this pt should include which of the following: a) periodic echocardiography b) exercise radionuclide venticulography c) exercise thallium-201 myocardial imaging d) cardiac catheterization Case

3. Progressive Obstruction to left ventricular outflow which results in PRESSURE overload of the left ventricle Aortic StenosisDefinition

4. Causes Subvalvular Supravalvular Valvular Congenital Bicuspid Rheumatic Degenerative (Calcific) Aortic StenosisCauses

5. Aortic Stenosis- Causes Today, Postinflammatory AS (mostly rheumatic AS) uncommon Bicuspid AS cause majority of AS in patietns under 50 Degenerative/Calcific AS cause majority of cases over 65 2002 1987

6. AS is the most common valvular abnormality in the elderly Calcific AS most common; 90% of AVR over age 75 Clinical risk factors have been identified; Pathologic studies suggest that Ao sclerosis and stenosis are extremes of the same disease process Aortic stenosis is an increasingly prevalent condition as the population ages AS Facts

7. Progessive obstruction leads to Progessive pressure overload on the LV Development of LVH/ Diastolic dysfuction Initially, this is compensatory, Maintain LV systolic function Maintain LV chamber size Eventually; Decrease in systemic and Coronary flow from obstruction Ventricular dilation Progessive LV dysfunction Pathophysiology

8. AS – Natural History/Symptoms

9. AS-Natural History

10. Grading of the Degree of Aortic Stenosis Aortic Stenosis , AVA, cm2 , AVA Index, cm2/m2 Mild 1.5 0.9 Moderate 1.0-1.5 0.6-0.9 Severe 0.8-1.0 0.4--0.6 Critical <0.8 <0.4 Rahimtoola,S.H.,Aortic Valve Disease,Hurst's Diseases of The Heart,10th Edition,Vol.2,Pp.1682-1695.

11. Guidelines for Relating Severity of Aortic Stenosis by Doppler Gradients in Adults with Normal Cardiac Output and Normal Average Heart Rate Peak Gradient MeanGradient AS severity mmHg mmHg <40 <30 Mild 40-60 30-50 Moderate >60 >50 Severe

12. Aortic StenosisManagement

13. Aortic StenosisManagement

14. Aortic Stenosis Physical Exam

15. Aortic StenosisMurmur Severe Mild More Severe AS Timing Early Mid Late LoudnessLoud Louder Softer A2 distinct Distinct Diminished/ Absent

16. 76 TABLE 4-4 -- RESPONSE OF MURMURS AND HEART SOUNDS TO PHYSIOLOGICAL AND PHARMACOLOGICAL INTERVENTIONS CLINICAL DISORDER INTERVENTION AND RESPONSE Systolic Murmurs Aortic outflow obstruction   Valvular aortic stenosis Louder with passive leg-raising, with sudden squatting, with Valsalva release (after five to six beats), following a pause induced by a premature beat, or after amyl nitrite; fades during Valsalva strain and with isometric handgrip   Hypertrophic obstructive cardiomyopathy Louder with standing, during Valsalva strain, or with amyl nitrite; fades with sudden squatting, recumbency, or isometric handgrip Aortic StenosisMurmur

17. Carotid Pulse Aortic Stenosis Normal “Pulsus Parvus et Tardus” (Slow and Late)

18. Carotid Pulse

19. Differentiating Systolic MurmursManeuvers Two Phases 1) Inspiratory Phase 2) Strain Phase

20. Incompetence of the aortic valve which results in primary VOLUME overload of the left ventricle Divided into Primary valvular insufffiency – Due to structural abnormality of the aortic valve Secondary valvular insuffiency – Due to dilation of the aortic annulus, usually due to diseases of the ascending aorta Aortic RegurgitationDefinition

22. AIPathophysiologyLV Dilation Aortic Insuffiency

23. Aortic InsuffiencyChronic vs Acute

24. Aortic InsuffiencyPhysical Exam

25. Acute severe AI Look sick hypotension S3 Rales Tachycardia Peripheral vasoconstriction – cold extremities Normal or minimally widened pulse pressure Early (shorter) diastolic murmur Aortic InsuffiencyPhysical Exam

26. Chronic Aortic Insuffiency De Musset sign – head bobbing Corrigan’s pulse – “water hammer pulse” Traube sign – “pistol shot” pulses heard with femoral auscultation Muller’ sign – the dancing uvula Duroziez’s sign- systolic murmur over FA with proximal FA compresssion, diastolic murmur over FA with distal FA compression Quincke’s sign – capillary pulsations in figer tips Widened pulse pressure Aortic InsufficiencyPhysical Exam

27. Medical - ?afterload reduction Surgical Symptomatic Aortic Insuffiency AVR Asymtomatic Aortic insuffiency 55-55 Rule AI- Management

28. An asymtomatic 48 yo man comes to your office for routine eval. He is physically active and jogs five miles 3 times weekly. He has no chest pain or syncope. He says a heart murmur was heard ten yrs ago during a physical exam but no f/u eval was done. BP is 130/70. A grade 3/6 crescendo-decrescendo murmur is heard at the base with a preserved second heart sound. A grade 2/6 diastolic murmur is heard at the left lower sternal border. The remainder of the exam in normal. Echo shows a bicuspid aortic valve. Mean aortic gradient is calculated to be 35mm Hg, and aortic regurg (3+) is noted. LVEF is 70% and left ventricular internal dimensions are normal. In addition to advice regarding SBE prophylaxis, mgmt of this pt should include which of the following: a) periodic echocardiography b) exercise radionuclide venticulography c) exercise thallium-201 myocardial imaging d) cardiac catheterization Case