1. Valvular Heart Disease Part 2: Aortic Valve

4. Aortic stenosis (AS)

5. AS-Etiology Senile calcification - CAD risk factors, ? use of statins Congenital - bicuspid most common, presents in adulthood - true congenital Rheumatic heart disease - mitral always involved as well

6. AS-Pathophysiology Pressure overload wall stress LV hypertrophy LVH leads to: 1. increased oxygen demand 2. reduced LV compliance, higher diastolic pressure at same volume 3. lower aortic pressure with reduced systemic perfusion and coronary blood flow

7. AS-Symptoms

8. Angina Increased O2 demand, decreased supply Mainly exertional Syncope Exertional- vasodilatation with fixed output Congestive heart failure Reduced compliance, eventually systolic dysfunction

9. AS-Physical diagnosis

10. PMI is sustained and laterally displaced Fourth heart sound Systolic murmur at base radiating to carotids, crescendo-decrescendo Time to peak of murmur, reduced second heart sound, pulsus parvus et tardus correlate with AS severity

11. AS-Diagnosis

13. AS-Medical therapy

14. AS-Surgical intervention Any appearance of symptoms Asymptomatic pts can be followed- –Consider ETT to evaluate FC In general, AVR

16. AS-surgical intervention Almost 100% restenosis at 6 mos.

17. Percutaneous valve replacement Symptomatic AS Not candidates/high-risk for surgery

19. AR-Etiology Diseases of the valve 1. Rheumatic heart disease 2. Calcific/degenerative 3. Rheumatoid arthritis, ankylosing spondylitis, SLE 4. Congenital-bicuspid, VSD, DSS

20. AR-Etiology Diseases of the aorta 1.Marfan’s, other connective tissue disorders 2. Hypertension 3. Tertiary syphillis 4. Aortic aneurysm\dissection (acute)

21. AR-Pathophysiology Extreme volume overload LV dilatation As in MR, LV function initially preserved but gradually decreases Unlike MR, no reduced afterload and only compensation is dilatation

22. AR-Pathophysiology Increased LV mass increases O2 demand Reduced aortic diastolic pressure leads to decreased coronary perfusion and reduced O2 supply

25. AR-Symptoms Long latent, asymptomatic period Symptoms generally appear after significant LV dilatation has already occurred. Congestive heart failure Rarely, angina due to decreased coronary perfusion

26. AR-Physical diagnosis Peripheral wide pulse pressure “waterhammer” or “pistol-shot” pulses head-bobbing, “dancing” uvula Cardiac PMI laterally and downwardly displaced Decrescendo diastolic murmur (sitting up) - duration correlated with severity Apical diastolic murmur (“Austin-Flint”)

27. AR-Medical therapy Afterload reduction- ACEI, hydralazine, nifedipine Unlike MR, randomized trials available Acute-immediately to OR

28. AR-Surgical intervention