Aortic stenosis

Clinical Features

• Dyspnea, chest pain, syncope
  • Once symptoms present mean survival is 2-3yr
• ejection systolic murmur radiating to carotids
• Pulsus parvus et tardus - slow to rise and late peaking
• Narrowed pulse pressure
• Soft 2nd heart sound

Differential Diagnosis

Valvular Emergencies

• Mitral stenosis
• Mitral regurgitation
  • Mitral valve prolapse
• Aortic stenosis
• Aortic regurgitation

Diagnosis

• Echocardiography, transthoracic
  • This will typically demonstrate minimal excursion of the aortic valve leaflet
  • Continuous wave doppler across the aortic valve with typically demonstrate high velocities
  • Color doppler will demonstrate turbulent flow across the valve
  • The left ventricle will demonstrate left ventricular hypertrophy
• Severity by CW Doppler velocity (m/s)
  • Ensure parallel intercept angle across aortic valve in apical view
  • <2.5 = aortic sclerosis
  • 2.6 - 2.9 = mild
  • 3.0 - 4.0 = moderate
  • >4.0 = severe

Management

• Avoid negative inotropes such as BBs, CCBs
• Afterload reduction is controversial and in decompensated AS should only be conducted in a monitored setting
  • Consider cards consult
• AS + A-fib = emergency
  • Consider emergent cardioversion
• Pulm edema
  • Diuretics, NIV, and intubation if necessary
  • Extreme caution with use of nitrates/vasodilators (preload reducers)
• In critical cases, particularly in those unstable to undergo emergent surgery, balloon aortic valvuloplasty may be an option as bridge to AVR or palliative care in nonsurgical candidates

Disposition

• Severe HF symptoms resistant to medical management require urgent surgery
• Class I indications for AVR:
  • Severe AS in symptomatic pt
  • Severe AS undergoing CABG, aortic, or valve surgery
  • Severe AS with LV dysfunction, EF < 50%

See Also

• Valvular emergencies
• Heart murmurs
• Cardiogenic shock