Aortic Stenosis

Presentation
Sir, this patient has Aortic stenosis that is severe in nature.
My findings include:
Presence of an ejection systolic murmur heard best at the aortic area and radiates to the
carotids. It is a grade 4! systolic murmur a" "ith a systolic thrill. It is severe as there is
an early ejection clic# a" a long systolic murmur "ith delayed pea#ing of the murmur. I
could not detect an S4 and the second heart sound is soft. $here "as also no parado%ical
splitting of the second heart sound.
$he ape% beat is heaving in nature and is displaced, located at the !
th
I& space at the just
lateral to the mid'clavicular line.
$his is associated "ith signs of congestive cardiac failure as evidenced by presence of
bibasal crepitations, raised ()P at * cm "ith prominent ) "ave and bilateral pedal edema
but she does not re+uire supplemental o%ygen.
Peripheral e%amination does not reveal any stigmata of I,. $he pulse is regular at -4bpm
and is anacroticpulsus parvus et tardus in nature. $here are no features suggestive of
haemolytic anaemia "ith no conjunctival pallor and patient is not jaundice.
I "ould li#e to complete my e%amination by ta#ing the patient.s blood pressure to loo#
for a narro" pulse pressure as "ell as his temperature chart. I "ould also li#e to en+uire
on patient.s symptoms of angina, syncope and dyspnea as these are important prognostic
mar#ers.
In summary, this patient has got aortic stenosis that is severe in nature "ith complication
of congestive cardiac failure. $here is no evidence of infective endocarditis or haemolytic
anaemia. $he most li#ely causes include /h heart disease, calcified biscupid aortic valve
or degenerative calcified aortic valves.
Questions
0hat are the differential diagnoses for an ejection systolic murmur1
AS
PS
23&M
M)PM/
&oarctation
2o" do you differentiate bet"een them1
AS and PS 4 e%piration and inspiration
AS and 23&M 4 )alsalva, s+uatting
AS and M)P 4 location and clic#s
AS and &oarctation 4 differential pulse
0hat are the types of pulses associated "ith aortic stenosis1
Pulsus parvus et tardus 4 means lo" volume pulse "ith delayed upstro#e due to a
reduction in systolic pressure and a gradual decline in diastolic pressure
Anacrotic pulse 4 small volume pulse "ith a notch on the upstro#e
0hat does a normal pulse volume in AS mean1
$he travsvalvular gradient is 567 mm2g
0hat does a palpable systolic thrill implies1
It means that the transvalvular gradient is 8 47mm2g
0hat does the second heart sound indicate about the aortic stenosis1
Soft second heart sound means poorly mobile and stenotic valve
/eversed splitting means mechanical or electrical prolongation of ventricular
systole9 S: is normally created by the closure of the aortic valve follo"ed by the
pulmonary valve, if the closure of the aortic valve is delayed enough, it may close
after the pulmonary, creating an abnormal parado%ical splitting of S:.
Single second heart sound implies fibrosis and fusion of the leaflets
;ormal second heart sound implies insignificant stenosis
0hat is <allavardin phenomenon1
Systolic murmur may radiate to"ards the ape%, "hich may be confused "ith a
M/ murmur
2o" can haemolytic anaemia result from aortic stenosis1
MA2A from severely calcified aortic valve
0hat are the causes of aortic stenosis1
/heumatic heart disease =5!7>
?egenerative calcification =8@6>
&alcified biscupid =!7'@6, males>
0hat are the severity mar#ers1
,arly ejection clic#
Aong Systolic murmur
Aate pea#ing of the murmur
4
th
heart sound
Parado%ical splitting of S:
2eaving ape% beat "hich is displaced
Systolic thrill
Pulsus parvus et tardus
;arro" pulse pressure
Symptoms =AS?> P%
Angina 6 years
Syncope * years
?yspnea =Most impt> : years
2o" do you differentiate AS from aortic sclerosis1
;o severity signs as above
,SM "hich is localised to aortic area "ith a normal S: in elderly person
2o" do patients present1
Asymptomatic and incidental finding
Angina
o Increase o%ygen re+uirement for hypertrophied A) "ith hypoperfusion of
the subendocardial myocardium
Syncope
o &ardiac arrythmias
o Peripheral vasodilatation eg post e%ercise "ithout concomitant increase in
&3
o $ransient elctromechanical dissociation
?yspnea
o Implies A) dysfunction and heart failure
2o" "ould you investigate1
,&< 4 A)2 "ith strain, B
st
degree heart bloc#, ACCC
&D/ 4 &alcified aortic valve, cardiomegaly, pulmonary congestion
:? echo
o ?%
o Severity
A)2, ,E

Severity Area $ransvalvular gradient

Mild 8B.6 5:6
Moderate B'B.6 :6'67
Severe 5B 67'-7
&ritical 57.@ 8-7
o &omplications eg I,
2o" "ould you manage1
,ducation
Medical
o Antibiotic prophyla%is
o /% complications such as arrythmias and &&E =caution "ith antihypt to
avoid reducing preload>
o Statins may have a role in reducing calcification of the aortic valve
Surgical treatment
o Indications
Symptomatic and severe
Asymptomatic but has
Area57.!
A) systolic dysfunction
2ypotension on e%ercise
)$
A)28B6mm
Moderate AS but going for S% for &AC<, M)/ or aortic root
surgery
o 3ptions
)alve replacement =S% of choice>
)alvuloplasty =for moribund patients>
0hat are your thoughts on a young person "ith AS murmur but a normal aortic valve1
Supravalvular stenosis
o &an be isolated or associated "ith 0illiams syndrome
o It is an inherited disorder, autosomal dominant, &h @
o Eeatures of elfin facies, hypertension and mental retardation "ith other
cardiac lesions such as PS
Subvalvular stenosis
0hat abdominal condition is associated "ith AS1
Angiodysplasia of the colon =P/ bleed>
0hat is pulse pressure1
?ifference bet"een systolic and diastolic pressure
;ormal 4 47mm2g
0ide ' 8!7 mm2g
;arro" ' 5:6mm2g
;ote: $here is no official definition but studies usually measures the pulse
pressure as a continuum