Aortic stenosis: Difference between revisions
No edit summary |
No edit summary |
||
| Line 40: | Line 40: | ||
**3.0 - 4.0 = moderate | **3.0 - 4.0 = moderate | ||
**>4.0 = severe | **>4.0 = severe | ||
[[File: | [[File:AVA continuity equation.PNG|thumbnail|AVA Continuity Equation]] | ||
[[File:Lvot diameter.jpg|thumbnail|LVOT Diameter (D in cm | [[File:Lvot diameter.jpg|thumbnail|LVOT Diameter (D) in cm]] | ||
==Management== | ==Management== | ||
Revision as of 01:54, 23 January 2017
Background
- Younger patients: usually from a congenital bicuspid valve
- Older patients: usually from calcifications on aortic valve
- Rhumatic heart disease is the next most common
- Significant obstruction when orifice <1 cm or pressure grad is >50 mmHg
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
Evaluation
- 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
- LV hypertrophy
- Number of leaflets (bicuspid, tricuspid, quadricuspid)[1]
- Raphe in bicuspid aortic valve in diastole may false negatively appear like trileaflet valve
- Only comment on the number of leaflets in systole in parasternal short axis
- Aortic valve area (AVA) requires LVOT diameter (D) and TVI at LVOT and AV in the continuity equation
- More reliable than CW doppler peak velocity as described below
- Obtain LVOT diameter at base of aortic valves in PSL at maximal systole
- LVOT VTI (pulse wave doppler), placed 5 mm proximal to aortic valve in apical view
- AV VTI (color wave doppler), placed 5 mm proximal to aortic valve in apical view
- Aortic stenosis valve area severity[2]
- Mild, > 1.5 cm²
- Moderate, 1.0 - 1.5 cm²
- Severe, < 1.0 cm²
- Severity by CW Doppler velocity (m/s)[3]
- 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 beta-blockers, calcium-channel blockers
- Afterload reduction is controversial and in decompensated AS should only be conducted in a monitored setting
- Consider cardiology consult
- AS + A-fib = emergency
- Consider emergent cardioversion
- Pulmonary 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
References
- ↑ Baumgartner H et al. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. European Journal of Echocardiography (2009) 10, 1–25.
- ↑ Saito T et al. Prognostic value of aortic valve area index in asymptomatic patients with severe aortic stenosis. Am J Cardiol. 2012 Jul 1;110(1):93-7.
- ↑ Baumgartner H, Hung J, Bermejo J, Chambers JB, Evangelista A, Griffin BP, Iung B, Otto CM, Pellikka PA, Quiñones M, American Society of Echocardiography, and European Association of Echocardiography. Echocardiographic assessment of valve stenosis: EAE/ASE recommendations for clinical practice. J Am Soc Echocardiogr. 2009 Jan;22(1):1-23; quiz 101-2.