Introduction

Aortic Stenosis is the narrowing of the three cusps that form the aortic valve. It is distinct from aortic sclerosis which is generally a milder precursor to aortic stenosis.

Aortic Stenosis is typically progressive, with symptoms becoming gradually worse over time. The first presentation usually occurs with shortness of breath on exertion.

Causes

Congenital

  • Bicuspid Valve
  • Williams Syndrome

Senile Calcification

  • THE most common cause
  • Look for corneal arcus
Aortic Stenosis

Aortic Stenosis seen on post mortem. The aorta has been removed in this image to better demonstrate the aortic valve

Signs

  • Ejection Systolic murmur best heard in the aortic area, ( Right 2nd intercostal space at border of sternum), radiating to the caroitds.
  • Slow-rising pulse, with a narrow pulse pressure (difference between systolic and diastolic pressures is small)
  • Heave – but apex beat is not displaced
  • Possible signs of:
 

Symptoms

  • Angina
  • Syncope
  • Dyspnoea
  • Signs of any valve defect
    • Fatigue
    • Dyspnoea

Investigations

ECG

  • L – LBBB – due do calcification
  • L – Left Axis Deviation
  • L – LVH
  • P – Poor R wave progression (i.e. depolarisation of the ventricles is slow)

Doppler Echo

Used to estimate the pressure across the valve.

  • 0 mmHg – normal valve
  • <30 mmHg – mild aortic stenosis
  • 30-50 mmHg – moderate aortic stenosis
  • >50 mmHg – severe aortic stenosis

Cardiac Catheterisation 

This can assess the actual gradient across the valve as well as check for co-existing CAD

Prognosis 

If untreated
This can be predicted with the presence of symptoms:
  • Angina present – 2 years
  • Syncope present – 1 year
  • Dyspnoea present – 6 months

Management

  • Surgicalif symptomatic, then the prognosis is poor (above) and prompt valve replacement is recommended. Valve replacement is also recommended for patients with ECG signs, and moderate to severe disease on Doppler / cardiac catheterisation.
    • Patients should be placed on antibiotics to prevent bacterial endocarditis
 
Valve replacements

Prosthetic – last about 10 years, after which time, may require another replacement. No need for long term anticoagulant therapy.
Metal last a life time, but require anticoagulant therapy for life. Also noisy (often make a loud ‘click’ sound). There are three types of metal valve

  • Tilting disc
  • Double tilting disc
  • Ball in a cage

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