Definition and Incidence of Aortic Stenosis [Luke]

Aortic stenosis is the narrowing of the aortic valve, restricting the flow of blood from the ventricle into the aorta.
Note: To avoid confusion, narrowing of the aorta itself is known as coarctation (of the aorta), a term which is actually
synonymous with stenosis.
Valvular Anatomy [Anthea]

Pulmonary valve
-Second Intercostal
Space
-Left Sternal Border

Tricuspid Valve
-Forth intercostal
space
-Left sternal border
Sitting Patient
forward may help

Aortic Valve
-Second
intercostal space
-Right Sternal
Border
Sitting Patient
forward may help
listening
Bicuspid (Mitral)
Valve
-Fifth intercostal
space
-Mid-clavicular line
Might be easier with

Symptoms of Aortic Stenosis [JJ]

Major symptoms :

Chest pain( angina)

Cardiac failure

Shortness of breath (dyspnoea)

Chest pain
Aortic stenosis is defined as abnormal valve opening or the aortic valves are unable to open fully, as a result the blood pumped out
from the heart is insufficient. Lack of blood flow causes the delivery of oxygen to the muscles lining the heart to become
insufficient. This results in chest pain. This occurs especially when the intensity of the exercise increases.
Causes

Congenital heart disease

o Aortic valve may be smaller than it should be
o Aortic valve may be bicuspid
Valve abnormalities
Rheumatic heart disease
o Can scar the aortic valve and narrow its opening
o Can also create a rough surface on which calcium deposits can collect
Calcium deposits
o Build-up of calcium can stiffen the aortic valve and interfere with its proper functioning
Due to protein collagen of the cusps being destroyed
Radiation treatment to the chest

Risk factors

Occurs more often in men than women, Old age

Congenitally unicuspid or bicuspid aortic valve

Rheumatic fever, Radiation, Atherosclerosis

DEFINITIONS
Preload Proportional to end-diastolic volume (basis of Frank-Starlings Law)
Afterload Pressure in the arterial system that resists ventricular ejection
Ejection Fraction Stroke volume divided by end-diastolic volume
Cardiac Output Volume of blood pumped into systemic circulation by heart per unit time
Venous Return Volume of blood returning to heart per unit time
Stroke Volume Volume of blood pumped out of heart per contraction (systole)
Cardiac (Ventricular) Contractility Pressure generated by ventricle during contraction
PATHOPHYSIOLOGY
Stenosis of the left ventricular outflow tract in aortic stenosis results in an increased afterload, which in turn leads to decreased
cardiac output. In order to compensate for this, cardiac contractility is increased via sympathetic feedback to generate higher
pressures in the left ventricle, in order to pump out enough blood through the stenotic aortic valve. The left ventricle thus needs to
work harder to generate the increased pressure required to maintain the mean arterial pressure at normal levels.

regions coloured red = pressure difference between the left ventricle and aorta, would have to be enlarged, as the left ventricles
would have to be generating more force to maintain the normal aortic pressure, indicated by the aortic pressure profile above, in
order to maintain cardiac output. The increased workload maintained by the left ventricle on a prolonged basis causes it to
undergo compensatory concentric myocardial hypertrophy. Over time, excessive ventricular hypertrophy can lead to
decompensation, with reduction in cardiac contractility, resulting in decreased stroke volume and thus cardiac output. The
pathophysiological mechanisms for this are unclear, although several theories have been put forward. These include change in
contractile protein gene expression, altered calcium ion flow and myocardial fibrosis secondary to chronic myocardial ischaemia.
Myocardial ischaemia results in an increase in myocardial tissue density without compensatory increase in vascular supply. There
is thus insufficient perfusion of the myocardial tissue, which now has an increased metabolic requirement due to its hypertrophic
state.

Investigations for Aortic Stenosis [Jess]

The Electrocardiogram (ECG)
Aortic stenosis itself is not diagnosable from the ECG but consequential symptoms are visible when compared to a normal ECG
Normal ECG

Heart catheterization
The heart may be catheterized to directly measure the pressure on both sides of the aortic valve. The pressure gradient may be
used as a decision point for treatment. Catheterization is accurate for moderate velocity stenosis, while Doppler echo is more
accurate at faster velocities

Simultaneous left ventricular and aortic pressure tracings demonstrate a pressure gradient between the left ventricle and aorta,
suggesting aortic stenosis. The left ventricle generates higher pressures than what is transmitted to the aorta. The pressure
gradient, caused by aortic stenosis, is represented by the green shaded area. (AO = ascending aorta; LV = left ventricle; ECG =
electrocardiogram.)
Heart catheterization
The heart can be catheterized to directly measure the pressure on both sides of the aortic valve.
The pressure gradient may be used as a decision point for treatment.
For moderate velocity stenosis - Catheterization
For faster velocities - Doppler echo

Echocardiogram - Echocardiogram (heart ultrasound) is the best non-invasive test to evaluate the aortic
valve anatomy and function.
Management of Aortic Stenosis [Peter]
Medical Care

Medical treatment essentially is reserved for patients who have complications of aortic stenosis such as heart failure,
infective endocarditis, hypertension or arrhythmias.

Surgical Care
Percutaneous balloon valvuloplasty (balloon valvotomy) - A balloon catheter is placed into the aortic valve that has become stiff
from calcium buildup. The balloon is then inflated in an effort to increase the opening size of the valve and improving blood flow.

Its used as a palliative measure in critically ill adult patients who are not surgical candidates or as a bridge in critically ill
patients before they undergo aortic valve replacement.
In children, adolescents, and young adults with congenital aortic stenosis is an accepted alternative to surgical valvotomy

Aortic valve replacement A cardiac surgery procedure in which a patient's aortic valve is replaced by a prosthetic valve
(mechanical, tissue).

In most adults with symptomatic severe aortic stenosis, aortic valve replacement is the surgical treatment of choice.
Patients who receive mechanical valve are at increased risk of blood clot formation and will be required to take
anticoagulation. Valves from animal donors dont require anticoagulation but require replacements.
The choice of prosthesis is determined by the anticipated longevity of the patients and their ability to tolerate
anticoagulation.
Aortic valve replacement can be done either with open heart surgery, or without it using a catheter instead (percutaneous
aortic valve replacement or PAVR).

Main Complications of Aortic Valve Stenosis [Dilini]

Pulmonary Oedema When there is aortic valve stenosis, the resistance in the aorta is much greater, hence the muscles in the
left ventricle thicken to maintain pump function and cardiac output (cardiomegaly). The thickening of the muscle means that it
becomes stiffer and a higher blood pressure in the left atrium and pulmonary venous system is needed to fill the left ventricle.
When there is an increase in the pulmonary capillary pressure within the lungs the fluid exchange between the vascular bed and
the interstitium is affected and an increased volume of fluid is exchanged causing pulmonary oedema.
Cardiomegaly- AS the left ventricle must pump harder to maintain the blood pressure within the systemic circulation it can
hypertrophy and thicken and enlarge (dilated). This will reduce the ventricles ability to pump blood. This will increase risk of
heart disease, AMIs, Heart Failure, Arrhythmias and cardiac arrest
Congestive Heart Failure- As the aortic valve is not functioning adequately the heart may be unable to pump enough blood to
meet the bodys needs causing congestive heart failure.
Heart Arrhythmias Because there is a problem with the aortic valves of the heart, in a severe aortic stenosis there may be
insufficient blood flow to the coronary arteries (which branch off the aorta after the Aortic Valve). The coronary arteries are vital
as they supply the SA Node and AV Node, the major conducting pathways of the heart. The degree of heart arrhythmias will be
dependent on the degree of aortic valve stenosis.
Myocardial Infarction In very severe Aortic Valve Stenosis, there may end up being a complete blockage of the blood vessels
which will cause an AMI. This occurs because of coronary artery obstruction; hence the part of the heart the specific coronary
artery or coronary artery branch supplies will die and become fibrous.
Bacterial Endocarditis - Increases the risk of bacteria entering your bloodstream and causing an infection in your heart,
specifically the endocardium layer of the heart.
If you have aortic stenosis, you may be required to take antibiotics before certain dental or medical procedures as a
preventative method.