Aortic Stenosis

In aortic stenosis area of the valve reduce to 1/3 or 1/4
of normal and result low cardiac output, decreases

coronary artery flow & left ventricle hypertrophy and
finally causes left ventricle failure.
Aortic stenosis is ¼ of all RVHD

Male predominant 80%
Aortic valve stenosis
Normal
Aortic valve
 Congenital
 Secondary due to rheumatic fever or calcification of
valve leaflet from unknown reason.
 When it’s congenital maybe it’s stenotic from born

and calcified in first six year and gradually it
become more stenotic.
 Bicuspid aortic valve
 Idiopathic calcific aortic stenosis
 Hypertrophic cardiomyopathy
 Discrete congenital subvalvular aortic
stenosis
 Supra valvular aortic stenosis
 Obstruction of blood flow from left ventricle
and cause variation in pressure of aorta and
left ventricle in systole.
 Pressure variation >50mmHg or
 Aortic valve < 0.5  1/3 > of normal
 Cause sever outflow obstruction
 Due to LV hypertrophy increased O2 demand
 1/3 > of normal become symptomatic
 If aortic stenosis progress gradually in years,

there is no symptoms till 5-7 decades.
 3 basic symptoms:
▪ Exertional dyspnea
▪ Syncope
▪ Angina pectoris
 In late stage when left ventricular failure occur

▪ Orthopnea
▪ PND
▪ pulmonary edema
 Due to Pulmonary hypertension:
 RT HF
 systemic veinous HTN
 atrial fibrillation
 Hepatomegaly
 tricuspid regurgitation
 are signs of terminal stage of aortic stenosis
 When MS is combined with aortic stenosis
 MS mask some sign of aortic stenosis

 MS
 Low cardiac output
 Decrease anginal attacks
 Delay valve calcification & LVH
 Pul. Congestion & Hemoptysis is more
prominent than pure MS
 BP is normal, but in late stage BP is down.
 Narrow pulse pressure
 In patient with sever aortic stenosis systemic

hypertension is unusual.
 Anacrotic pulse or pulse tardus
 Inspection:
 PMI is normal
▪ late stage PMI is shifted to left-lower
 Left ventricular heave

▪ in sever AS & thin patient
 Palpation:
 PMI is vigorous than normal and shifted to left-
lower
 Systolic thrill in jugular notch and extended to

carotid artery
 Left ventricular heave is palpated.

 Auscultation:
 regular rhythm,
 if combined with MS (Atrial fibrillation)
 Systolic ejection (Opening snap)

 congenital non calcified patient
 Paradoxical splitting of the second heart sound

 S4 & S3
 Mid systolic MM:
 Low pitch, Rasping, diamond ship, sometime
musical, 2nd ICS right side of sternum, radiated to
jugular notch & carotid artery and it’s various from
& grade 1 to 6
 DDx from Systolic MM of MR
 Left ventricular failure:

 Basal crepitation
 Left ventricle concentric hypertrophy
 Round PMI
 Radiologic signs of pulmonary congestion:
 Dilatation of left atrium, pulmonary artery, right
atrium & right ventricle.
 Fluoroscopy & Echo shows aortic valve
calcification
 Signs of left ventricle hypertrophy
 ST-segment depression & T inversion in
▪ lead I , avL and left ventricle pericardial leads
 LBBB
 RBBB
 Complete AV block
 Thickening of :
 Left ventricle wall & septum, calcification and
inactive cuspus of aortic valve
 Doppler echocardiography shows difference

of pressure in both side of aortic valve
 TEE is more sensitive

 Before surgery left ventricle catheterization
should be done.
 Catheterization:
 evaluation of severity of obstruction of aortic valve
 left ventricle function
 location of obstruction from left ventricle
 Evaluation of left ventricle volume
 Thickness of left ventricle septum
 Location of obstruction
 Deformity of aortic valve and movement of
cusps
 Ascending aorta diameter
 Mitral insufficiency
 Evaluation of sclerosis in aortic valve
 Determination of Calcium
 Hemodynamic changes due to AS
 Sever AS
 Death occur in old age
 Average age is 63
 Death cause:
▪ 10-20% suddenly maybe arrhythmia
▪ 0.5-2.3% CHF
▪ Autopsy sing of old or fresh infarction
 Dx:
 sign
 Symptoms
 Lab. Exam
 DDx:
 Left ventricular failure
 Hypertrophic obstructive cardiomyopathy
 Valvular
 congenital heart disease
▪ VSD and coarctation of aorta
 Sudden death
 CHF
 Left ventricle failure
 Conduction defect
 Infective endocarditis 20%
 All patients need accurate fallow up
 Avoid sever physical exertion
 Treatment of CHF:
 Salt restriction
 Digoxin
 diuretics & vasodilators
 Statins: slow the calcification of leaflets

 Indication:
 1cm> /Sq m of body
 Left ventricle dysfunction
 Sever dilatation in aortic root after AS
 Surgery is best method

 Valve replacement for Calcify Aortic Stenosis
 After valve replacement 10 year survival rate
is 60%
 Almost 30% of bioprosthetic valves after 10

year shows signs of insufficiency and needs
recurrent replacement.
 Rose method
 Percutaneous balloon aortic valvuloplasty is

alternative treatment in young people with
congenital aortic stenosis.

Aortic Stenosis

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In aortic stenosis area of the valve reduce to 1/3 or 1/4

of normal and result low cardiac output, decreases

Aortic stenosis is ¼ of all RVHD

 When it’s congenital maybe it’s stenotic from born

 If aortic stenosis progress gradually in years,

 In late stage when left ventricular failure occur

 MS mask some sign of aortic stenosis

 In patient with sever aortic stenosis systemic

 Left ventricular heave

 Systolic thrill in jugular notch and extended to

 Left ventricular heave is palpated.

 Systolic ejection (Opening snap)

 Paradoxical splitting of the second heart sound

 Left ventricular failure:

 Doppler echocardiography shows difference

 TEE is more sensitive

 Statins: slow the calcification of leaflets

 Surgery is best method

 Almost 30% of bioprosthetic valves after 10

 Percutaneous balloon aortic valvuloplasty is

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