Cardiology: Aortic Valve Disease

Aortic stenosis

• Causes;
  • Senile calcification (commonest)
  • Congenital – bicuspid valve, William’s syndrome
• Presentation;
  • Angina
  • Dyspnoea
  • Dizziness
  • Faints
  • Systemic emboli if infective endocarditis
  • CCF
  • Sudden death
• Signs
  • Slow rising pulse with narrow pulse pressure
  • Heaving, non-displaced apex beat
  • LV heave
  • Aortic thrill
  • Ejection systolic murmur which radiates to the carotids
• Tests
  • ECG – P-mitrale, LVH with strain pattern, LAD, LBBB or complete AV block (calcified rings)
  • CXR – LVH, calcified aortic valve, post-stenotic dilation of the ascending aorta
  • ECHO – diagnostic, severe stenosis if gradient >50mmHg and valve area <0.5cm
• Differential diagnosis
  • HOCM
• Management
  • If symptomatic then prognosis is poor – 2-3yr survival if angina/syncope, 1-2yr if cardiac failure
  • Prompt valve replacement is recommended if symptomatic or if not symptomatic but with severe AS and deteriorating ECG

Aortic regurgitation

• Causes;
• Congenital
• Rheumatic fever
• IE
• RA, SLE
• Aortic root disease;
• Hypertension
• Trauma
• Aortic dissection
• Seronegative arthropathies – AS, Reiter’s syndrome, psoriatic arthropathy
• Marfan’s syndrome
• Osterogenesis imperfecta
• Syphilitic aortitis
• Symptoms
• Dyspnoea
• Palpitations
• Cardiac failure
• Signs
• Water hammer pulse
• Wide pulse pressure
• Displaced hyperdynamic apex beat
• High pitched early diastolic murmur best heard in expiration with patient sitting forward
• Corrigan’s sign – carotid pulsation
• De Musset’s sign – head nodding
• Quincke’s sign – capillary pulsation in nail beds
• Duroziez’s sign – femoral diastolic murmur as blood flows backward in diastole
• Traube’s sign – pistol shot femorals
• In severe AF an Austin flint murmur may be heard
• Tests
• ECG – LVH
• CXR – cardiomegaly, dilated ascending aorta, pulmonary oedema
• ECHO
• Cardiac catheterisation
• Management
• Indications for surgery
• Increasing symptoms
• Enlarging heart on CXR/Echo
• ECG deterioration (T wave inversion)
• Infective endocarditis refractive to surgery 
• Aim to replace the valve before significant dysfunction occurs