Case 3

Aortic Stenosis
Reem Abdellatif 181210031
Mariam Samy 171210077
Enas Taha 171210008
Khulood Alrabyee 161210139
 SOEPEL
Subjective Objective Learning Objectives
• 79-year-old man
• Several episodes of Lightheadedness • Describe the anatomy of
Cardiac examination:
• He felt as about to faint while climbing a flight aortic valve
• Laterally displaced and
of stairs, but the symptom passed after he sat • Discuss the pathology of
sustained apical impulse
down. • bicuspid aortic valve
Grade 3/6 ejection systolic
• He does not have chest pain when he walks • State the causes of Aortic
murmur
• He denies shortness of breath, dyspnea on stenosis.
• loudest at the base of the
exertion, orthopnea, and paroxysmal nocturnal • Explain the hemodynamics
heart, radiating to the neck
dyspnea. of the cardiovascular system
• Grade 1/6 high-pitched,
History : blowing, early diastolic in Aortic stenosis
• In the past he has experienced episodes of • Describe the
murmur along the left sternal
retrosternal chest pressure with strenuous border. pathophysiological
exertion • S4 is audible consequences of Aortic
• He has no significant family history stenosis.
• He smokes 20 cigarettes a day Plan • Review the cardinal clinical
•ECG presentations of Aortic
Evaluation (DDx) stenosis, explain each in
•CXR
term of pathophysiology.
• Aortic stenosis.
•Echocardiography. • Illicit the physical findings of
• Acute Coronary Syndrome. Aortic stenosis.
•Serum Electrolyte Levels
• Outline the management of
• Hypovolemic Shock. patients with Aortic stenosis,
Elaboration including the medical and
• hypertrophic obstructive surgical
Heart valve replacement
cardiomyopathy
 Causes of AS:

• Bicuspid aortic valve.>30

• Degenerative calcification >70 Normal valve Aortic stenosis
• Rheumatic aortic valve disease 30-70
DEGENERATIVE CALCIFICATION
 HAEMODYNAMIC INSTABILITIES IN AS
Compensatory mechanisms
Because valve disease is generally a chronic problem, two compensatory mechanism occur to
maintain normal cardiac output and arterial pressure:
◦ Neurohumoral activation: Systemic vasoconstriction, increased blood volume,increased heart rate and inotropy.
◦ cardiac remodelling: (hypertrophy)
- When there is changes in the cardiac pressures and
volumes it will associated with chronic valve stenosis - Right picture: show
- Left picture: During and there will be absence of systolic failure the effect of the aortic
ventricular ejection > the valve stenosis on the
left ventricular pressure left ventricular
will exceeds aortic pressure pressure volume loop
> systolic murmur is > end systolic volume
present between S1 and S2 increase ( there is no
(the grey colour large change in the end
pressure gradient across the diastolic volume) >
aortic valve during systole) stroke volume
> left atrial pressure is decrease > ventricular
elevated > aortic pressure hypertrophy> reduced
reduced because of ventricular compliance
decrease of stroke > elevation end
volume.> increase diastolic pressure.
 Pathophysiologic consequence
Impeded blood flow during systole:
Elevation of left ventricular systolic pressure > concentric hypertrophy LV > reduces the
compliance of the ventricle

Elevation of diastolic LV pressure > LA hypertrophy > provide more than 25% of the stroke
volume to the stiffened LV

CO at rest is within normal limits in most patients with severe AS, it usually fails to rise
normally during exercise

Complications that could happen:

- Microangiopathic haemolytic anaemia: RBC damage( schistocyte ) as they squeeze
through small valve opening.
- Development atrial fibrillation: Hypertrophy going to cause:
1. reducing wall stress 2. reduces compliance of the ventricular
This will result in: increase of diastolic left ventricular pressure and will cause left
atrium hypertrophy.
- Irreversible myocardial fibrosis develops: Excessive hypertrophy becomes
maladaptive, LV systolic function declines, abnormalities of diastolic function
progress,
- Heart failure.

Cardinal Clinical Presentation
Clinical Manifestation
On Physical Examination
abnormal heart sounds ( S2 Harsh, systolic, cresendo-decresendo systolic murmur at upper
sternal border radiating to carotids + S4 Gallop )
Carotid thrill
Pulsus parvus et tardus
Narrowed pulse pressure.
Signs of Atrial Fibrillation and Heart Failure ( LATER STAGE )
 Investigations
◦ ECG :Nonspecific for AS or Signs of left ventricular
hypertrophy (left axis deviation, positive Sokolow-Lyon index)
◦ Chest x-ray :Findings of left ventricular hypertrophy, such as
left ventricular enlargement and rounded heartapex, usually
only in decompensated aortic stenosis, and possibly left atrial
enlargement as well Calcification of aortic valve and prominent,
dilated, ascending aorta( post-stenotic dilatation)
◦ echocardiography: Transthoracic (TTE) or transesophageal
(TEE)Findings include concentric hypertrophy, narrowing of the
opening of the aortic valve, and increased mean pressure
gradient across the aortic valve.
◦ Left-heart catheterization:
 Management
Medical:
strenuous physical activity and competitive sports should
be avoidedavoid dehydration and hypovolemia
Medications for hypertension or CAD: beta blockers and
ACE inhibitor are safe Nitroglycerin for relieving angina
pectoris
statins may slow progression of leaflet calcification and
aortic valve area reduction

Surgical:
-Asymptomatic patients should be under regular review for
assessment of symptoms and echocardiography.
-Surgical intervention for asymptomatic people with severe
aortic stenosis is recommended if:
- Symptoms during an exercise test or with a drop in blood
pressure
-A left ventricular ejection fraction of <50%
-Moderate–severe stenosis undergoing CABG, surgery of
-the ascending aorta or other cardiac valve.
- Symptomaticsurgery
 Case Reflection
A 79-year-old man presented to his general practitioner with several episodes of Lightheadedness. During
these episodes, he felt as about to faint while climbing a flight of stairs, but the symptom passed after he
sat down. He does not have chest pain when he walks, although in the past he has experienced episodes
of retrosternal chest pressure with strenuous exertion. He denies shortness of breath, dyspnea on
exertion, orthopnea, and paroxysmal nocturnal dyspnea. He has no significant family history. He smokes
20 cigarettes a day. On physical examination, he is afebrile, blood pressure is 120/70 mm Hg, pulse rate is
67/min, and respiration rate is 14/min. Cardiac examination reveals a laterally displaced and sustained
apical impulse. He has a grade 3/6 ejection systolic murmur, loudest at the base of the heart, radiating to
the neck, and a grade 1/6 high-pitched, blowing, early diastolic murmur along the left sternal border. An S4
is audible. Lungs are clear to auscultation. Abdominal examination is benign. He has no lower extremity
edema.
Transthoracic echocardiogram shows normal left ventricular systolic function. Aortic valve area is 0.8 cm2.
The mean gradient is 44 mm Hg, with a peak gradient of 53 mm Hg.
A chest X-ray was reported as showing a slightly large heart.

ECG: left ventricular hypertrophy (sum of negative deflection in VI and positive deflection
in V5 or V2and V6 greater than 35 mm)

What is the most common cause of
aortic stenosis in a person less than
the age of 70 years old?
A. Senile calcific aortic stenosis
B. Rheumatic aortic stenosis
C. Bicuspid aortic valve
D. Inflammatory disorders such as
rheumatoid arthritis or systemic lupus
erythematosus
C C
Questions
What structural change of the
heart is most commonly
associated with any patient with
aortic stenosis regardless of the
etiology?
A. Left ventricular chamber
enlargement
B. Left atrial enlargement
C. Left ventricular hypertrophy
D. Right ventricular enlargement
What is the classic mechanism or
etiology of the symptoms of
syncope in the setting of aortic
stenosis?
A. Ventricular arrhythmias
B. Decreased cerebral perfusion
from inadequate cardiac output
C. Bradyarrhythmias including
advanced AV blocks
D. Vasovagal syncope
B
 Thanks!
Do you have any questions?

References :
● Lilly, L., n.d. Pathophysiology of heart disease.
● Osmosis.
● https://www.amboss.com/us/knowledge/Aortic_valve_s
tenosis

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