1. AORTIC VALVE
Aortic Valve is located at the junction of LV outflow tract and ascending Aorta.
Aortic valve consists of 3 components – annulus, cusp and commissure.
Aortic valve have 3 cusp – one located on the anterior wall(right coronary cusp)& two located in the posterior wall(left and posterior cusp)
Cusp are fold of endocardium with central fibrous core.
Each cusp have thick basal border, deeply concave on its aortic aspects and horizontal free margins.

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Behind each cusp aortic wall bulges to form aortic sinus of valsava.
Coronary arteries arise form the sinus(right coronary artery – anterior cusp, left coronary artery – left posterior cusp)
Aortic valve consisted of annulus but there is no complete collagenous ring supporting the attachment of leaflet
Commusures form tall peacked space between the attachment of adjacent cusp and attain the level of aortic sinotubular junction
Aortic cusp form central closure line in diastole, in systole the cusp open and close again at the end systole when aortic pressure exceeds the LV pressure

4. Normal valve area (cm2) _ 2.5 – 3.5cm2
Normal velocity of aorta (m/s) – 1 – 1.7 m/s

5. AORTIC STENOSIS Narrowing of aortic orifice
Aortic stenosis develops slowly except in congenital form
Aortic stenosis occurs in three levels
Valvular Aortic Stenosis(Causes)
Rheumatic Heart Disease
Calcific Aortic Stenosis associated with increasing age
Congenital Bicuspid Valve(A bicuspid valve is found in 40% of middle aged individual with aortic stenosis and 80% of elderly individual with aortic stenosis
Bicuspid Aortic valve is congenital abnormality affecting 1-2% of population and result in cusp which separate normally but usually have eccentric closure line which may lie interiorly or posteriorly.

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Sub Valvular Aortic Stenosis(caused by obstruction proximal to AV)
Sub aortic membrane
Hypertrophic cardiomyopathy
Tunnel Sub aortic obstruction
Upper septal bulge – this is due to fibrosis and hypertrophy usually seen in elderly individual
Supra Valvular Aortic Stenosis
This occur in some congenital condition such as Williams syndrome (which includes hypercalcemia, growth failure and mental retardation)

9. Normal valve area Peak Velocity (m/s) Peak gradient(mmHg)
Mild
Moderate
Severe <0.75
Peak Velocity (m/s)
Normal 1.0
Mild – 2.0
Moderate
Severe >4.0
Peak gradient(mmHg)
Normal <10
Mild <20
Moderate
Severe >64

10. Valvular Aortic stenosis

12. Clinical Features Symptoms Mild to Moderate AS is usually asymptomatic
Exertional Dyspnea
Angina
Exertional Syncope
Sudden Death
Episode of acute Pulmonary Edema
Signs
Ejection systolic murmer
Slow rising carotid pulse
Narrow pulse pressure
Thirsting apex beat(LV pressure overload)
Signs of pulmonary venous congestion

13. Investigation ECG – LVH, LBBB X-ray - LV enlargment Echocardiogram
2D Echo
Cusp may seen thickened, calcific reduced motion or may dome
There may be LVH due to pressure overload
LV dilatation occur if heart failure has developed
Post stenotic dilatation of aorta may be seen
Doppler Turbulant flow.
Can asses the severity of AS by estimating the pressure gradient across the AV.

14. Management
Patient with symptomatic AS and valve gradient indicative of moderate or severe stenosis(>50 mm Hg)should have valve replacement
Aortic Balloon Valvuloplasty is useful in congenital aortic stenosis
Anticoagulants are required only if patient have atrial fibrillation or have valve replacement with mechanical prosthesis

15. Aortic Regurgitation
This is leakage of blood from aorta to LV during diastole
Causes:
# Congenital
Bicuspid valve or disproportionate cusp
# Accquired
Rheumatic Disease
Infective Endocarditis
Trauma
Aortic Dilatation(Marfan syndrome, anneurysm, dissection, syphyllis)

17. Clinical Features Symptoms Mild – moderate AR often asymptomatic
Awareness of heart beat “pulsation”
Severe AR – Breathlessness, Angina
Signs
Pulse
Large volume or collapsing pulse
Bounding peripheral pulse
Capillary pulsation in nail bed _Quineke’s Sign
Femoral bruit
Head nodding with pulse
Murmur
early diastolic murmur
systolic murmur
Austin flint murmur (soft mid diastolic)
Other Signs
Displaced rocking apex beat
Fourth heart beat sound
Pulmonary Venous Conjestion

18. INVESTIGATION ECG – LVH X-ray – Cardiac Dilatation, features of LVH
Echocardiogram
M mode and 2D Echo – LV dilatation with severe AR, progressive dilatation with symptoms or left ventricular end systolic diametre in excess of 5.5cm
Pulse Vave Doppler
Can give idea of severity by seeing how far into the LV cavity the AR jet reaches
Mild AR remains within the area of AV
Moderate AR remains between the LVOT & level of mitral valve above papillary muscle level
Severe AR extend to LV apex
Continuous Wave Doppler
The slope of deccelaration rate of the doppler signal of AR can give an indication of severity

19. Doppler
High velocity turbulent flow in diastole because of aliasing direction of flow is not seen correctly but dominant doppler signal are above the base line.

20. Management Treatment for endocarditis
AVR indicated if AR causes symptoms
Vasodilators have been shown to prevent left ventricular dilatation
When aortic root dilatation is cause of AR aortic root replacement may be necessary