1. Aortic Stenosis
Obstruction to outflow is most commonly localized to the aortic valve. However, obstruction may also occur above or below the valve.

2. Netter

3. etiology

4. Aortic Stenosis Etiology
Congenital
Unicuspid produce severe obstruction in infancy and is fatal
Bicuspid Valves
Occurs in 2% of the population and is the most common congenital cardiac defect in the adult
Presents with stenosis earlier in life
Abnormal architecture leads to turbulent flow and fibrosis

5. Normal and Congenital Valves
Tricuspid Valve
Unicuspid Valve
Bicuspid Valve

6. Aortic Stenosis Etiology
Acquired
Rheumatic
Results from adhesion and fusion of the commissures and cusps leading to retraction and stiffening of the free borders with calcific nodules
The valve is often regurgitant as well, and is often accompanied by evidence of MV involvement
Degenerative (Senile)
The cusps are immobilized by a deposit of calcium along the flexion lines in their bases

7. Rheumatic and Calcified Valves
Calcific Bicuspid
Valve
Rheumatic
Valve
Calcific Tricuspid
Valve

8. Mixed Valves Congenital Bicuspid Valve affected by Rheumatic
Disease and Calcification
Tricuspid Valve with
Rheumatic Disease
creating a functional bicuspid
valve, and calcification

9. Aortic Stenosis Clues to diagnosis
Aortic Regurgitation Isolated AS
or MV involvement with calcification
Rheumatic under 70 yrs. Old over 70 yrs. Old
bicuspid valve senile degeneration

10. Aortic Stenosis Pathophysiology
Outflow obstruction
Outflow Resistance
Concentric Hypertrophy
Maintain CO & SV
LV Compliance
Diastolic Pressure
Enhanced LA contraction
Maintain LV filling S4

11. Aortic Stenosis Clinical Manifestations
History
Angina
Occurs in 2/3 of patients with critical AS
Half of the patients have normal coronaries
Results from increased oxygen demand by a hypertrophied myocardium and decreased oxygen delivery secondary to compression of the vessels
Average survival is 5 years

12. Aortic Stenosis Clinical Manifestations
History
Syncope
Due to reduced cerebral perfusion
May be orthostatic, exertional, medication related (nitrates, diuretics, etc.), or due to arrhythmias
Average survival is 3 years

13. Aortic Stenosis Clinical Manifestations
History
Heart Failure
Manifest as orthopnea, dyspnea, PND, pulmonary edema
Average survival is 1 – 2 years

14. Aortic Stenosis Clinical Manifestations
Physical Examination
Venous System
Venous pulse configuration and pressure are unremarkable in well compensated AS
An increased A wave may occur as a result of decreased RV compliance secondary to LVH (Bernheim effect)

15. Aortic Stenosis Clinical Manifestations
Physical Examination
Carotid Arterial Pulse
The classic arterial pulse is called pulsus parvus et tardus (slow and late)
Precordium
The apical impulse has a sustained lift
There is little or no leftward displacement of the PMI

16. Aortic Stenosis Clinical Manifestations
Physical Examination
Auscultation
S1 – usually normal, may be soft if CHF present
S2 – the intensity of A2 decreases as the valve stiffens
S2 splitting – with prolongation of LV ejection time A2 will occur later than P2 and cause paradoxical splitting of S2

17. Aortic Stenosis Paradoxical Splitting
A P
Inspiration
Expiration

18. Aortic Stenosis Clinical Manifestations
Physical Examination
S3 – usually not a normal finding in aortic stenosis, it’s presence suggests LV dysfunction
S4 – is usually present and suggests LV hypertrophy and decreased LV compliance
Ejection click occurs when the leaflets abruptly halt after maximal upward excursion and imply a mobile valve. It disappears as the valve becomes severely calcified.

19. Murmur of Aortic Stenosis
Heard best at the 2nd
RICS radiating to the
carotids, sometimes
throughout the
precordium.
S4 S 1
S 2

20. Aortic Stenosis Severity
Mild
Moderate
Severe

21. x-ray

22. ekg

23. Normal Tricuspid Valve
tee
Calcified Valvular Stenosis

24. Echocardiogram of Aortic Valve

25. Doppler Evaluation of the Valve

26. Catheterization of the Aortic Valve

27. Aortic Stenosis Natural History
Symptomatic Patients
Angina = 5 year
Syncope = 3 year
CHF = 1-2 years
Asymptomatic Patients
4% risk of sudden death

28. Aortic Stenosis Medical Management
All patients should follow SBE prophylaxis guidelines
Avoid vigorous exercise
Use nitrates and diuretics with caution
Asymptomatic patients should report the onset of any symptoms promptly

29. Prosthetic Valves

30. Prosthetic Valves

31. Aortic Stenosis Surgical Management

32. Aortic Stenosis Valvuloplasty

33. Aortic Regurgitation