Aortic Stenosis

• What is aortic stenosis?

  Narrowing of aortic valve

  Can be due to several different factors (atherosclerosis, calcification & fibrosis)
• What is the pathophys of aortic stenosis?

  Lipid accumulation in aortic valve leaflets -> attracts macrophages -> inflammation -> over time, fibrosis & Ca+2 deposition -> valve leaflets become stiff & immobile -> become thicker & calcified -> restricts opening during systole -> increased pressure gradient across aortic valve during LV ejection -> LV hypertrophy -> diastolic dysfunction & decreased coronary perfusion -> ischaemia & HF
• What are the DDx of aortic stenosis?


  Coronary artery disease

  HF

  Cardiac arrhythmia

  Other valvular disorders (aortic sclerosis, mitral regurgitation, hypertrophic cardiomyopathy etc.)
• What are the RFs of aortic stenosis?


  Over 65 (due to age-related calcification)

  Congenital bicuspid aortic valve (predisposes to early calcification & stenosis)

  Rheumatic heart disease

  Radiation therapy

  Metabolic disorders (e.g. familial hypercholesterolaemia)
• What are the signs & symptoms of aortic stenosis?


  Can be asymptomatic

  Exertional dyspnoea

  Exertional angina

  Exertional syncope or presyncope

  Loud mid-to-late peaking systolic ejection murmur (radiates to carotids & becomes more prominent when sitting forward & on expiration)
• What are the signs & symptoms of severe aortic stenosis?

  • Slow-rising and low volume carotid pulse (pulsus parvus et tardus) (May not be present in elderly due to stiff vascular vessels)
  • Soft or absent second heart sound (S2)
  • Narrow pulse pressure
  • Reverse splitting of S2
  • Heaving apex beat or systolic thrill
  • Signs of heart failure - pitting lower limb oedema, bilateral basal crackles
  • S4
• What are the possible complications of aortic stenosis?

  HF

  Sudden cardiac death

  Arrhythmias

  GI bleeding

  Endocarditis
• What are the Inx for AS?


  ECG (may show arrhythmias or signs of LV strain)

  CXR

  Transthoracic echocardiogram (TTE) -> diagnostic test for AS

  Exercise stress testing -> to unmask symptoms

  Dobutamine stress echocardiogram

  BNP -> assess for HF

  Multi-slice CT -> shows extent of calcification

  Cardiac MRI -> to quantify myocardial fibrosis

  Cardiac catheterisation -> not routinely done
• What is the definitive treatment for AS?


  surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI)
• What are the indications for surgery in AS?


  Symptomatic

  Severe AS (Classified as aortic jet velocity ≥4 m/s, mean transvalvular pressure gradient ≥ 40 mmHg, and aortic valve area ≤1 cm2)
• What is the conservative management of AS?


  Treating HF

  Maintaining sinus rhythm

  Controlling HTN

  Serial testing & follow up
• What is the classic triad of symptoms in aortic stenosis?

  HF

  Syncope

  Angina