Aortic stenosis is a progressive lesion but asymptomatic till late, often presenting after 50 years of age. Symptoms indicate severe disease (signs of severity in italics).
Pulse
- small volume
- slow upstroke
- decreased systolic / pulse pressure (not in elderly with stiff
- plateau pulse
Palpation
- hyperdynamic apex beat
- systolic thrill – sitting forward, full expiration
Auscultation
- single / reversed S2 ± soft / absent A2
- harsh, mid-systolic murmur at apex, radiating to sternal notch and carotids
- ± ejection click (associated aortic incompetence)
- S4
- paradoxical splitting S2
- signs of left ventricular failure
- length, lateness of peak of murmur
- manoeuvres
Causes:
- < 65 years
- 60% unicuspid or bicuspid (i.e. congenital)
- 20% rheumatic valvular disease
- 20% degenerative calcific
- > 65 years
- 90% degenerative calcific
Differential Diagnosis:
- aortic flow murmur
- pulmonary stenosis
- hypertrophic obstructive cardiomyopathy
- pulmonary flow murmur of ASD
- supra-valvular obstruction
- narrowing
- fibrous diaphragm
- sub-valvular obstruction
- membranous diaphragm
- fibrous ridge
During a long latent period with increasing outflow tract obstruction, which results in increasing left ventricular pressure load, patients remain asymptomatic and acute complications are rare. However, as soon as symptoms such as exertional dyspnoea, angina, or dizziness and syncope occur, outcome becomes dismal […] sudden death—although not uncommon common in symptomatic patients—appears to be a very rare event in asymptomatic AS (< 1%/year) … [yet is] probably the major concern for asymptomatic patients with severe AS followed conservatively.¹
Symptoms:
- angina pectoris: almost 100% 5-year mortality
- syncope: almost 100% 3-year mortality
- dyspnoea / heart failure: almost 100% 2-year mortality
ECG:
- left ventricular hypertrophy (LVH)
- (left atrial enlargement)
CXR:
- left ventricular hypertrophy
- valve calcification (lateral film)
ECHO:
- valve cusp mobility
- left ventricular hypertrophy
- Doppler estimation of gradient
- valve < 1 cm^2 (severe)
- PSG > 50 mm Hg
Complications:
- infective endocarditis
- cerebral emboli – TIA / CVA
- sudden death – symptomatic patients
Management:
Asymptomatic
- 6-monthly follow-up
- annual echo / doppler
- endocarditis prophylaxis
Surgery
Because symptoms reflect decompensation and an increased mortality, they are an indication for surgery. Other indications for surgery include severe stenosis with valve area < 0.75 cm^2 and PSG > 100 mmHg. Moreover, left ventricular dysfunction and progressive cardiomegaly are also indications for surgery.
- TAVR
- operative
- a 5% operative risk is even greater if
- increasing age
- left ventricular failure
- ventricular arrhythmia
- coronary artery disease
- direct vision commissurotomy or balloon valvuloplasty
- valve replacement
- prosthesis (anticoagulation)
- a 5% operative risk is even greater if
