Common Clinical Scenarios *Younger people *Younger people _Functional murmur vs _Functional murmur vs _ MVP vs _ MVP vs _ AS _ AS *Older people _Aortic sclerosis vs _Aortic stenosis

Aetiology Young patient _Thick congenital bicuspid valve valve *2% population *2% population *3:1 male:female *3:1 male:female *Co-existing COA 6% patients *Co-existing COA 6% patients _Rarely _Rarely *Unicuspid valve *Unicuspid valve *supravalvular AS *supravalvular AS *Subaortic stenosis *Subaortic stenosis _Discrete _Discrete _Diffuse { Tunnel} _Diffuse { Tunnel} Middle age {40- 50y } _Thick bicuspid valve _Rheumatic disease Old age {60- 80y} _Thick degenerative valve _Calcification of bicuspid valve _Rheumatic AS

Aortic Stenosis Subvalvular Supravalvular Valvular (HCM; IHSS

COP maintained normal for years by progressive LVH _ Coronary blood flow becomes inadequate Exertional Angina _LV outflow obstruction limits COP after exercise Exertional syncope _LVEDP raise Pulmonary congestion Dyspnoea,Pulmonary oedema _Patients asymptomatic for long time once symptoms appear deteriorate rapidly

Clinical features: *Cardinal Symptoms _ Mild or moderate AS usually asymptomatic _ Mild or moderate AS usually asymptomatic _ Chest pain (angina ) _ Chest pain (angina ) Rreduced coronary flow reserve Rreduced coronary flow reserve Increased demand-high afterload Increased demand-high afterload _ Syncope/Dizziness (exertional pre-syncope) _ Syncope/Dizziness (exertional pre-syncope) Fixed cardiac output Fixed cardiac output Vasodepressor response Vasodepressor response _ Dyspnoea on exertion & rest _ Dyspnoea on exertion & rest Impaired exercise tolerance Impaired exercise tolerance _Episodes of acute pulmonary oedema _Episodes of acute pulmonary oedema _Sudden death _Sudden death * Other signs of LV failure Diastolic & systolic dysfunction Diastolic & systolic dysfunction

Clinical features cont.. *Signs _Ejection systolic murmer _Slaw rising carotid pulse _Narrow pulse pressure _Thrusting apex beat { LV pressure overload } _Signs of pulmonary congestion { basal crepitation }

Auscultation : S1 S2 Mild-Moderate Severe

Some points about physical signs : _ Intensity DOES NOT predict severity _ Intensity DOES NOT predict severity _Presence of thrill DOES NOT predict severity _Presence of thrill DOES NOT predict severity Conditions indicating severity: Conditions indicating severity: _ ” Diamond ” shaped, harsh, systolic crescendo- decrescendo {Long murmer} _ ” Diamond ” shaped, harsh, systolic crescendo- decrescendo {Long murmer} _Decreased, delay & prolongation of pulse amplitude {Anacrotic pulse } _Decreased, delay & prolongation of pulse amplitude {Anacrotic pulse } _Paradoxical S2 _Paradoxical S2 _S4 (with left ventricular hypertrophy) _S4 (with left ventricular hypertrophy) _S3 (with left ventricular failure) _S3 (with left ventricular failure)

* ECG _ LVH _ LBBB _May be normal * Chest XR _Enlarged LV _Dilated Ascending aorta _May be normal _Calcified AV * ECHO _Calcified AV with restricted opening _Thickened LV walls *Dopler _ Estimates gradient _detects AR *Cardiac Catheterization : _Systolic gradient between LV and Aorta _Post-stenotic dilatation of aorta _Detects AR if present _To detect presence of CAD

ECG

PA LL Chest X-ray

2-d ECHO LX Calcified cusps Subvalvuler

Natural history _Heart failure reduces life expectancy to less than 2 years _Heart failure reduces life expectancy to less than 2 years _Angina and syncope reduce life expectancy between 2 and 5 years _Angina and syncope reduce life expectancy between 2 and 5 years _Rate of progression 0.1 cm2/year _Rate of progression 0.1 cm2/year

ECHO (cont.) Criteria for determining severity of AS Criteria for determining severity of AS G (mmHg) AVA (cm 2 ) Mild < 25 > 1.5 Moderate Severe Critical>80<0.7

* Medical _ Prophylaxis against IE _ Anticoagulants if in AF _Diuretics cautiously for pulmonary congestion _Vasodilators are CONTRAINDICATED * Surgical _ Patients with symptoms and valve gradient >50 and normal COP should have AV replacement { Mechanical } _ Symptomatic Elderly patients need AV replacement with {Bioprosthesis} _ Aortic Balloon valvoplasty for congenital AS

Disc Valve Bio-prosthetic Valve Caged-Ball Valve

Comparison between Mechanical and Prosthetic Valves * MECHANICAL _Durable _Durable _Large orifice _Large orifice _High thromboembolic potential _High thromboembolic potential _Best in Left Side _Best in Left Side _Chronic warfarin therapy _Chronic warfarin therapy BIO-PROSTHETIC _Not durable _Smaller orifice/functional stenosis _Low thromboembolic potential _Consider in elderly _Best in tricuspid position

Common Murmurs and Timing (click on murmur to play) Systolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiency Diastolic Murmurs Aortic insufficiency Mitral stenosis S1 S2 S1