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Aortic Valve (AV)

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  • • Usually tricuspid, composed of fibrous skeleton, 3 cusps, and sinuses of Valsalva

    • Free edge of each cusp is concave and thicker, with fibrous node at midpoint

    • Eddy currents in sinuses of Valsalva prevent occlusion of coronary ostia during systole

    • Cusps fall closed and coapt, supports ejected column of blood during diastole

    • Coronary arteries arise from 2 of 3 sinuses of Valsalva

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Aortic Stenosis (AS)

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  • • Can be subvalvular, valvular, or supravalvular

    Etiology in adult: Congenital unicuspid, bicuspid valve; congenital subvalvular or supravalvular stenosis; rheumatic heart disease; or degenerative fibrosis and calcification (most common)

    • LV outflow obstruction leads to concentric LV hypertrophy: decreased diastolic compliance, maintained ejection fraction (EF)

    • Atrial systole important for LV filling

    • Atrial fibrillation may precipitate congestive heart failure (CHF)

    • LV hypertrophy leads to increased myocardial oxygen consumption, coronary artery disease (present in 25-50%), more myocardium at jeopardy

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Epidemiology

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  • Causes of valve disease

    • -Rheumatic carditis (most common)

      -Valve collagen degeneration

      -Infection

      -Less common causes include collagen-vascular disease, tumors, carcinoid, and Marfan syndrome

    • Valvular heart disease: 89,000 hospital discharges in 1998

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AS

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  • • Likely congenital if patient is < 30 years old

    • Likely bicuspid valve if patient is 30-65 years old

    • Likely degenerative if patient is > 65 years old

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Symptoms and Signs

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  • • Most asymptomatic for many years

    Triad: Angina, syncope, CHF

    • Aortic valve gradient > 50 mm Hg, or valve area < 1 cm2 usually symptomatic

    • Angina from inadequate oxygen delivery

    • Syncope usually exertional

    • CHF is late finding and ominous sign

    • Narrowed pulse pressure

    • Decreased systolic pressure (parvus et tardus)

    • Harsh midsystolic murmur: second intercostal space along left sternal border, radiating to carotids, not axilla or apex

    • 25-50% also have aortic regurgitation murmur

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Laboratory Findings

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  • ECG: LV hypertrophy

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Imaging Findings

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  • Chest film: Heart usually normal size (may be dilated if CHF present), post-stenotic aortic dilation, calcified aortic valve

    Transesophageal echocardiography (TEE): Evaluate for calcification, valve mobility, bicuspid anatomy, LV hypertrophy, EF, valvular gradients, aortic regurgitation

    Cardiac catheterization: Coronary anatomy, cardiac output, transvalvular pressure gradients, LV function, coexisting valvular lesions

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  • TEE: Evaluate for calcification, valve mobility, bicuspid anatomy, LV hypertrophy, EF, valvular gradients, aortic regurgitation

    Cardiac catheterization: Coronary anatomy, cardiac output, transvalvular pressure gradients, LV function, coexisting valvular lesions

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  • Mild AS: Aortic valve area > 1.5 cm2

    Moderate AS: 1-1.5 cm2

    Severe AS: ≤ 1 cm2

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  • Balloon valvotomy: Limited role due to high restenosis rate within 6 mos; may be option if patient is decompensated with severe heart failure as a "bridge"

    Valve replacement: Mechanical or porcine

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Surgery

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Indications

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