Valvular

Aortic stenosis (MC valve dz in rich places)

PATHO

  • Narrowed aortic valve ➔ aortic obstruction ➔ ↓ output

    • Aortic valve sclerosis (calcification/fibrosis)

    • Bicuspid Valve ↑ in ♂ (MC congenital valve issue)

    • Rheumatic fever

  • Obstruction ➔ ↑ afterload ➔ ↑ LV pressure ➔ concentric hypertrophy ➔ impaired filling

  • Sclerosis ↑ in > 75yo. Same kinda thing as atherosclerosis

  • Congenital could be unicuspid or bicuspid, more likely to get calcification earlier ➔ pt presents younger

SSX

  • Dyspnea (usually on exertion)

  • Chest pain

  • Syncope/weak (parvus) & delayed (tardus) pulses ➔ tachy (to compensate)

  • Narrow pulse pressure (Systolic BP - Diastolic BP = pulse pressure)

  • Early systolic click ➔ Systolic Crescendo-Decrescendo murmur that can radiate to carotid

    • Squatting/supine ➔ ↑ preload ➔ ↑ murmur (leaning forward also ↑ murmur)

    • Valsalva/standing ➔ ↓ preload ➔ ↓ murmur (handgrip ➔ ↑ afterload ➔ ↓ murmur)

  • S4 - active filling into hypertrophied ventricles (from AS)

DX

  • ECHO (Transthoracic) calcification and narrow aortic valve with concentric hypertrophy

    • Pick this unless they ask the definitive dx

  • EKG shows LVH

  • CXR (because they complained of dyspnea) shows calcified aortic valve, dilated aorta after site of stenosis

  • Definitive: cardiac catheterization

  • Cardiac cath (if noninvasive data are nondiagnostic) assesses aortic valve, aortic pressure gradient, cardiac output

TX

  • Severe sx or asx with severe stenosis (low ejection fraction) needs valve replacement

    • No exercise til surgery

  • Serial echos for ASX

    • No restrictions but educate about good dental hygiene (↑ risk of infective endocarditis)

  • Percutaneous (transcatheter) aortic-valve replacement (TAVR) if high surgery risk

  • Surgical valve replacement if low risk OR you have to go in anyway because of all the multi-vessel CAD

  • Percutaneous balloon valvuloplasty for congenital valve that hasn't stenosed yet (younger pts)