Aortic Stenosis
Presentation
Sir, this patient has Aortic stenosis that is severe in nature.
My findings include:
Presence of an ejection systolic murmur heard best at the aortic area and radiates to the
carotids. It is a grade 4/6 systolic murmur a/w with a systolic thrill. It is severe as there is
an early ejection click a/w a long systolic murmur with delayed peaking of the murmur. I
could not detect an S4 and the second heart sound is soft. There was also no paradoxical
splitting of the second heart sound.
The apex beat is heaving in nature and is displaced, located at the 6th IC space at the just
lateral to the mid-clavicular line.
This is associated with signs of congestive cardiac failure as evidenced by presence of
bibasal crepitations, raised JVP at 3 cm with prominent V wave and bilateral pedal edema
but she does not require supplemental oxygen.
Peripheral examination does not reveal any stigmata of IE. The pulse is regular at 84bpm
and is anacrotic/pulsus parvus et tardus in nature. There are no features suggestive of
haemolytic anaemia with no conjunctival pallor and patient is not jaundice.
I would like to complete my examination by taking the patient’s blood pressure to look
for a narrow pulse pressure as well as his temperature chart. I would also like to enquire
on patient’s symptoms of angina, syncope and dyspnea as these are important prognostic
markers.
In summary, this patient has got aortic stenosis that is severe in nature with complication
of congestive cardiac failure. There is no evidence of infective endocarditis or haemolytic
anaemia. The most likely causes include Rh heart disease, calcified biscupid aortic valve
or degenerative calcified aortic valves.
Questions
What are the differential diagnoses for an ejection systolic murmur?
 AS
 PS
 HOCM
 MVP/MR
 Coarctation
How do you differentiate between them?
 AS and PS – expiration and inspiration
 AS and HOCM – Valsalva, squatting
 AS and MVP – location and clicks
 AS and Coarctation – differential pulse
What are the types of pulses associated with aortic stenosis?
 Pulsus parvus et tardus – means low volume pulse with delayed upstroke due to a
reduction in systolic pressure and a gradual decline in diastolic pressure
 Anacrotic pulse – small volume pulse with a notch on the upstroke
What does a normal pulse volume in AS mean?
 The travsvalvular gradient is <50 mmHg
What does a palpable systolic thrill implies?
 It means that the transvalvular gradient is > 40mmHg
What does the second heart sound indicate about the aortic stenosis?
 Soft second heart sound means poorly mobile and stenotic valve
 Reversed splitting means mechanical or electrical prolongation of ventricular
systole; S2 is normally created by the closure of the aortic valve followed by the
pulmonary valve, if the closure of the aortic valve is delayed enough, it may close
after the pulmonary, creating an abnormal paradoxical splitting of S2.
 Single second heart sound implies fibrosis and fusion of the leaflets
 Normal second heart sound implies insignificant stenosis
What is Gallavardin phenomenon?
 Systolic murmur may radiate towards the apex, which may be confused with a
MR murmur
How can haemolytic anaemia result from aortic stenosis?
 MAHA from severely calcified aortic valve
What are the causes of aortic stenosis?
 Rheumatic heart disease (<60)
 Degenerative calcification (>75)
 Calcified biscupid (60-75, males)
What are the severity markers?
 Early ejection click
 Long Systolic murmur
 Late peaking of the murmur
 4th heart sound
 Paradoxical splitting of S2
 Heaving apex beat which is displaced
 Systolic thrill
 Pulsus parvus et tardus
 Narrow pulse pressure
 Symptoms (ASD)
Px
Angina
5 years
Syncope
3 years
Dyspnea (Most impt)
2 years
How do you differentiate AS from aortic sclerosis?
 No severity signs as above
 ESM which is localised to aortic area with a normal S2 in elderly person
How do patients present?
 Asymptomatic and incidental finding
 Angina
o Increase oxygen requirement for hypertrophied LV with hypoperfusion of
the subendocardial myocardium
 Syncope
o Cardiac arrythmias
o Peripheral vasodilatation eg post exercise without concomitant increase in
CO
o Transient elctromechanical dissociation
 Dyspnea
o Implies LV dysfunction and heart failure
How would you investigate?
 ECG – LVH with strain, 1st degree heart block, LBBB
 CXR – Calcified aortic valve, cardiomegaly, pulmonary congestion
 2D echo
o Dx
o Severity
 LVH, EF

Severity
Area
Transvalvular gradient
Mild
>1.5
<25
Moderate
1-1.5
25-50
Severe
<1
50-80
Critical
<0.7
>80
o Complications eg IE
How would you manage?
 Education
 Medical
o Antibiotic prophylaxis
o Rx complications such as arrythmias and CCF (caution with antihypt to
avoid reducing preload)
o Statins may have a role in reducing calcification of the aortic valve
 Surgical treatment
o Indications
 Symptomatic and severe
 Asymptomatic but has
 Area<0.6
 LV systolic dysfunction
 Hypotension on exercise
 VT
 LVH>15mm
 Moderate AS but going for Sx for CABG, MVR or aortic root
surgery
o Options
 Valve replacement (Sx of choice)
 Valvuloplasty (for moribund patients)
What are your thoughts on a young person with AS murmur but a normal aortic valve?
 Supravalvular stenosis
o Can be isolated or associated with Williams syndrome
o It is an inherited disorder, autosomal dominant, Ch 7
o Features of elfin facies, hypertension and mental retardation with other
cardiac lesions such as PS
 Subvalvular stenosis
What abdominal condition is associated with AS?
 Angiodysplasia of the colon (PR bleed)
What is pulse pressure?
 Difference between systolic and diastolic pressure
 Normal – 40mmHg
 Wide - >60 mmHg
 Narrow - <25mmHg
 Note: There is no official definition but studies usually measures the pulse
pressure as a continuum