Valvular Heart Disease: Aortic Stenosis and Aortic Insufficiency - - PowerPoint PPT Presentation

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Valvular Heart Disease: Aortic Stenosis and Aortic Insufficiency - - PowerPoint PPT Presentation

Aug 13, 2023 181 likes •680 views

Valvular Heart Disease: Aortic Stenosis and Aortic Insufficiency Ivan Anderson, MD RIHVH Cardiology Outline Structure of the Aortic Valve Causes of Aortic Stenosis and Insufficiency Prognosis Assessment and Follow-up of Aortic

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SLIDE 1

Ivan Anderson, MD

RIHVH Cardiology

Valvular Heart Disease: Aortic Stenosis and Aortic Insufficiency

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SLIDE 2

Outline

  • Structure of the Aortic Valve
  • Causes of Aortic Stenosis and Insufficiency
  • Prognosis
  • Assessment and Follow-up of Aortic Stenosis
  • r Aortic Insufficiency
  • Therapies
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SLIDE 3

Outline

  • Structure of the Aortic Valve
  • Causes of Aortic Stenosis and Insufficiency
  • Prognosis
  • Assessment and Follow-up of Aortic Stenosis
  • r Aortic Insufficiency
  • Therapies
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SLIDE 4

Aortic Valve in Diastole

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SLIDE 5

Aortic Valve in Systole

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SLIDE 6

Outline

  • Structure of the Aortic Valve
  • Causes of Aortic Stenosis and Insufficiency
  • Prognosis
  • Assessment and Follow-up of Aortic Stenosis
  • r Aortic Insufficiency
  • Therapies
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SLIDE 7

Outline

  • Structure of the Aortic Valve
  • Causes of Aortic Stenosis and Insufficiency
  • Prognosis
  • Assessment and Follow-up of Aortic Stenosis
  • r Aortic Insufficiency
  • Therapies
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SLIDE 8

Stenotic Aortic Valve

Normal Rheumatic Bicuspid Calcific

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SLIDE 9

Pathophysiology of Aortic Stenosis

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Causes of Aortic Insufficiency

  • 50% Valve Disease

– Bicuspid valve – Infective Endocarditis – Calcific valvular disease – Rheumatic valvular disease

  • 50% Root disease

– Marfan syndrome, aortopathy of various varities

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SLIDE 11

The Aortic Root

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SLIDE 12

Leaflet Failure and Root Dilation as Causes of Aortic Insufficiency

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SLIDE 13

Verma S, Siu SC. N Engl J Med 2014;370:1920-1929.

Patterns of Bicuspid Aortopathy, with Representative Findings

  • n Echocardiography and Computed Tomography (CT).
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Verma S, Siu SC. N Engl J Med 2014;370:1920-1929.

Pathophysiological Features of Bicuspid Aortopathy.

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SLIDE 15

Hemodynamics and Murmur

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Aortic Valve Area

  • Normal: 4 cm2
  • Mild Aortic Stenosis: 1.5-2.0 cm2
  • Moderate Aortic Stenosis: 1.0-1.5 cm2
  • Severe Aortic Stenosis: < 1.0 cm2
  • Typically narrowing progresses at 0.1 cm2/yr,

but variable

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SLIDE 17

Parasternal Long Axis LA LV RVOT AoV

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SLIDE 18
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SLIDE 19

Parasternal Long

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SLIDE 20

AP3/AP Long Axis View LA LV AoV

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Outline

  • Structure of the Aortic Valve
  • Causes of Aortic Stenosis and Insufficiency
  • Prognosis
  • Assessment and Follow-up of Aortic Stenosis
  • r Aortic Insufficiency
  • Therapies
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SLIDE 22

Outline

  • Structure of the Aortic Valve
  • Causes of Aortic Stenosis and Insufficiency
  • Prognosis
  • Assessment and Follow-up of Aortic Stenosis
  • r Aortic Insufficiency
  • Therapies
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SLIDE 23

Prognosis (Classic Teaching)

  • If Angina is present, mean life expectancy is 5

years

  • If Syncope is present, mean life expectancy is

3 years

  • If CHF is present, mean life expectancy is 2

years

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SLIDE 24

Leon MB et al. N Engl J Med 2010;363:1597-1607.

Partner 1 Outcomes

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SLIDE 25

A Closer Look

50% 1-year mortality with no valve replacement 30% 1-year mortality with TAVR

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SLIDE 26

Outline

  • Structure of the Aortic Valve
  • Causes of Aortic Stenosis and Insufficiency
  • Prognosis
  • Assessment and Follow-up of Aortic Stenosis
  • r Aortic Insufficiency
  • Therapies
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SLIDE 27

Outline

  • Structure of the Aortic Valve
  • Causes of Aortic Stenosis and Insufficiency
  • Prognosis
  • Assessment and Follow-up of Aortic Stenosis
  • r Aortic Insufficiency
  • Therapies
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SLIDE 28

Left Ventricular Outflow Trace Aortic Valve

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SLIDE 29
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SLIDE 30

Errors in Estimating Valve Area

  • Typically arise in echocardiography from an

inaccurate measurement of the left ventricular outflow tract

  • Hence, typically gradient is used
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SLIDE 31

Velocity Across the Aortic Valve and Area

Stage Mean Gradient (mmHg) Jet Velocity (m/s) Aortic Valve Area (cm2) Normal 0-9 1 3-4 Mild 10-20 <3 > 1.5 Moderate 20-40 3-4 1.0-1.5 Severe

  • 40
  • 4

< 1.0

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SLIDE 32

Hemodynamics and Murmur of Aortic Insufficiency

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SLIDE 33

Follow-up Interval with Echocardiogram for Aortic Insufficiency

  • Mild (severity): echo every 3-5 years
  • Moderate : echo every 1-2 years
  • Severe: echo every 6-12 months, more often if

LV is dilating

JACC Vol. 63, No. 22, 2014

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SLIDE 34

Physical Signs with Severe AI

  • De Musset sign: head bobs with heartbeat
  • Water hammer pulse
  • Traube sign: booming systolic and diastolic

sounds heart over femoral artery

  • Muller sign: systolic pulsation of uvula
  • Duroziez sign: systolic mumur with compression
  • f the femoral arery proximally and diastolic

mumur when compressed distally

  • Quincke sign: capillary pulsations with

transmitting light through the fingernails

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SLIDE 35

Follow-up Interval with Echocardiogram for Aortic Stenosis

  • Mild (severity): echo every 3-5 years
  • Moderate : echo every 1-2 years
  • Severe: echo every 6-12 months

JACC Vol. 63, No. 22, 2014

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SLIDE 36

Outline

  • Structure of the Aortic Valve
  • Causes of Aortic Stenosis and Insufficiency
  • Prognosis
  • Assessment and Follow-up of Aortic Stenosis
  • r Aortic Insufficiency
  • Therapies
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SLIDE 37

Outline

  • Structure of the Aortic Valve
  • Causes of Aortic Stenosis and Insufficiency
  • Prognosis
  • Assessment and Follow-up of Aortic Stenosis
  • r Aortic Insufficiency
  • Therapies
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SLIDE 38

Rick A. Nishimura et al. JACC 2014;63:e57-e185

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SLIDE 39

Surgery with Severe Aortic Stenosis

  • Symptomatic (Ia)
  • LVEF < 50% (Ia)
  • Undergoing other cardiac surgery (Ia)
  • Vmax > 5.0 m/s or mean gradient > 60 mmHg

(IIa)

  • Abnormal Exercise Treadmill Test (IIa)
  • Vmax increasing > 0.3 m/s per year and low

surgical risk

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SLIDE 40

Rick A. Nishimura et al. JACC 2014;63:e57-e185

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SLIDE 41

Surgery with Severe Aortic Insufficiency

  • Symptomatic (Ia)
  • LVEF < 50% (Ia)
  • Undergoing other cardiac surgery (Ia)
  • LVEF ≥ 50% and LV end systolic dimension > 50

mm (IIa)

  • LVEF ≥ 50% and LV end diastolic dimension >

65 mm (IIa)

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SLIDE 42

Left Ventricular End Systolic Dimension

End Systolic Dimension

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SLIDE 43

Left Ventricular End Diastolic Dimension

LV End Diastolic Dimension

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SLIDE 44

Risk Estimation Surgical Versus Percutaneous Aortic Valve Replacment

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SLIDE 45

Surgical Aortic Valve

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SLIDE 46

Smith CR et al. N Engl J Med 2011;364:2187-2198.

Transcatheter Aortic-Valve Replacement.

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SLIDE 47

Leon MB et al. N Engl J Med 2016;374:1609-1620.

Time-to-Event Curves for the Primary Composite End Point.

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SLIDE 48

Aortic Valve Replacement Leading to Complete Heart Block

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SLIDE 49

Questions