 Aortic stenosis  Heart failure  Dr.Aso faeq salih

a narrowing of the valve that opens to allow blood to flow from the left ventricle into the aorta and then to the body.

 Valvular, subvalvular or supravulvalar – 5%  Failure of : ◦ development of the three leaflets ◦ Resorption of tissue around the valve

 Depend on degree of stenosis  Mild to moderate : asymptomatic  Severe: ◦ easy fatigability, exertional chest pain, syncope ◦ In infant with severe stenosis can survive only if:  PDA permits flow to the aorta and coronary arteries

Physical sign: – Small volume, slow rising pulse – Sys ejection murmur at Rt 2nd IS and radiating to neck – ejection click – Thrill at RUS border/suprasternal notch/carotid Cong bicuspid aortic valve: – Prone to calcific degeneration in middle age – Increased risk of infective endocarditis

(a) Aortic stenosis. (b) Murmur. (c) Chest X-ray. (d) ECG.

 Ballon valvulopasty ◦ Symptoms on exercise/ high resting pressure gradient(>64mmHg) ◦ High risk of significant valvular insufficiency  Surgical mx ◦ When BV unsuccesful or significant valvular insufficiency develops  Subacute bacterial endocarditis prophylaxis

 Salt &water retention by kidney  increase pre load.  Vasoconstriction, through Renin / Angiotensin  increase after load.  Increased circulating Catecholamine  increase C.O.  Increase R.R to promote excretion of Co2.  Increase renal excretion of H- ion & retention of HCO3 to maintain a normal PH.

 The primary determinants of SV :  Pre load (volume work ).  After load ( pressure work ).  Contractility (intrinsic myocardial function )

 Cardiac rhythm disorders may be caused by the following: Complete heart block, Supraventricular tachycardia, Ventricular tachycardia, Sinus node dysfunction  Volume overload may be caused by the following: 1.Structural heart disease (eg, ventricular septal defect, [3] patent ductus arteriosus, aortic or mitral valve regurgitation, complex cardiac lesions) 2.Anemia 3.Sepsis

 Pressure overload may be caused by the following: Structural heart disease (eg, aortic or pulmonary stenosis, aortic coarctation) Hypertension  Systolic ventricular dysfunction or failure may be caused by the following: Myocarditis, Dilated cardiomyopathy Malnutrition, Ischemia  Diastolic ventricular dysfunction or failure may be caused by the following: Hypertrophic cardiomyopathy, Restrictive cardiomyopathy, Pericarditis, Cardiac tamponade (pericardial effusion)

Depends on the degree of cardiac reserve.  Infants :  Feeding difficulties & sweating.  Poor weight gain.  Irritability & weak cry.  Respiratory distress.

 Fatigue.  Effort intolerance.  Anorexia, abdominal pain.  Dyspnea.  Cough.  Orthopnea.

Respiratory distress. Increased JVP. Hepatomegally. Edema. Basal crepitation. Cardiomegaly. Gallop rhythm. Holosystolic murmur of mitral, tricuspid insufficiency.

 CXR  cardiac enlargement, pul. vascularity.  ECG : chamber hypertrophy, ischemic changes, rhythm disorders.  Echo : assess ventricular function.  Doppler ; calculate C. O.  Arterial O2 : may be decreased ( pul. Edema ).  Blood gas analysis : metabolic & respiratory acidosis.  Electrolyte disturbances : hypo Na, hypo glycemia.

 Underlying cause must be removed or alleviated if possible.  General measures : Adequate sleep & rest. Position : older children  semi upright position infants  infant chair. Modification of activities. Diet :  increase no. of calories / feeding up to 24 cal/oz, or supplementing breast feeding.

 Low Na formula is not recommended.  Older children : diet with (no added salt ) & abstinence from food containing high concentration of salts.  Respiratory distress :  Semi upright position.  Continuous O2, +ve pressure ventilation.  _ ve inotropic factors should be corrected : hypoglycemia, hypo Ca, acidosis.  Sedation for irritability & excessive crying.  Treatment of associating pul. Infection.  Temperature control.

 Medications used in treating HF :  Diuretics.  Inotropic agents.  After load reducing agents.