AORTIC VALVE

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AORTIC VALVE

• Aortic Valve is located at the junction of LV
  outflow tract and ascending Aorta.
• Aortic valve consists of 3 components annulus,
  cusp and commissure.
• Aortic valve have 3 cusp one located on the
  anterior wall(right coronary cusp) two located
  in the posterior wall(left and posterior cusp)
• Cusp are fold of endocardium with central fibrous
  core.
• Each cusp have thick basal border, deeply concave
  on its aortic aspects and horizontal free margins.

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• Behind each cusp aortic wall bulges to form
  aortic sinus of valsava.
• Coronary arteries arise form the sinus(right
  coronary artery anterior cusp, left coronary
  artery left posterior cusp)
• Aortic valve consisted of annulus but there is no
  complete collagenous ring supporting the
  attachment of leaflet
• Commusures form tall peacked space between the
  attachment of adjacent cusp and attain the level
  of aortic sinotubular junction
• Aortic cusp form central closure line in
  diastole, in systole the cusp open and close
  again at the end systole when aortic pressure
  exceeds the LV pressure

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• Normal valve area (cm2) _ 2.5 3.5cm2
• Normal velocity of aorta (m/s) 1 1.7 m/s

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AORTIC STENOSIS

• Narrowing of aortic orifice
• Aortic stenosis develops slowly except in
  congenital form
• Aortic stenosis occurs in three levels
• Valvular Aortic Stenosis(Causes)
• Rheumatic Heart Disease
• Calcific Aortic Stenosis associated with
  increasing age
• Congenital Bicuspid Valve(A bicuspid valve
  is found in 40 of middle aged individual
  with aortic stenosis and 80 of elderly
  individual with aortic stenosis
• Bicuspid Aortic valve is congenital
  abnormality affecting 1-2 of population and
  result in cusp which separate normally but
  usually have eccentric closure line which may
  lie interiorly or posteriorly.

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• Sub Valvular Aortic Stenosis(caused by
  obstruction proximal to AV)
• Sub aortic membrane
• Hypertrophic cardiomyopathy
• Tunnel Sub aortic obstruction
• Upper septal bulge this is due to fibrosis
  and hypertrophy usually seen in elderly
  individual
• Supra Valvular Aortic Stenosis
• This occur in some congenital condition such as
  Williams syndrome (which includes hypercalcemia,
  growth failure and mental retardation)

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• Normal valve area
• Normal 2.5 - 3.5
• Mild 1.5 - 2.5
• Moderate 0.75-1.5
• Severe lt0.75
• Peak Velocity (m/s)
• Normal 1.0
• Mild 1.0 2.0
• Moderate 2.0-4.0
• Severe gt4.0
• Peak gradient(mmHg)
• Normal lt10
• Mild lt20
• Moderate 20-64
• Severe gt64

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Valvular Aortic stenosis
Valvular Aortic stenosis.
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Clinical Features

• Symptoms
• Mild to Moderate AS is usually asymptomatic
• Exertional Dyspnea
• Angina
• Exertional Syncope
• Sudden Death
• Episode of acute Pulmonary Edema
• Signs
• Ejection systolic murmer
• Slow rising carotid pulse
• Narrow pulse pressure
• Thirsting apex beat(LV pressure overload)
• Signs of pulmonary venous congestion

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Investigation

• ECG LVH, LBBB
• X-ray - LV enlargment
• Echocardiogram
• 2D Echo
• Cusp may seen thickened, calcific reduced
  motion or may dome
• There may be LVH due to pressure overload
• LV dilatation occur if heart failure has
  developed
• Post stenotic dilatation of aorta may be
  seen
• Doppler Turbulant flow.
• Can asses the
  severity of AS by estimating the pressure
  gradient across the AV.

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Management

• Patient with symptomatic AS and valve gradient
  indicative of moderate or severe stenosis(gt50 mm
  Hg)should have valve replacement
• Aortic Balloon Valvuloplasty is useful in
  congenital aortic stenosis
• Anticoagulants are required only if patient have
  atrial fibrillation or have valve replacement
  with mechanical prosthesis

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Aortic Regurgitation

• This is leakage of blood from aorta to LV during
  diastole
• Causes
• Congenital
• Bicuspid valve or disproportionate cusp
• Accquired
• Rheumatic Disease
• Infective Endocarditis
• Trauma
• Aortic Dilatation(Marfan syndrome, anneurysm,
  dissection, syphyllis)

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Clinical Features

• Symptoms
• Mild moderate AR often asymptomatic
• Awareness of heart beat pulsation
• Severe AR Breathlessness, Angina
• Signs
• Pulse
• Large volume or collapsing pulse
• Bounding peripheral pulse
• Capillary pulsation in nail bed _Quinekes Sign
• Femoral bruit
• Head nodding with pulse
• Murmur
• early diastolic murmur
• systolic murmur
• Austin flint murmur (soft mid diastolic)
• Other Signs
• Displaced rocking apex beat
• Fourth heart beat sound
• Pulmonary Venous Conjestion

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INVESTIGATION

• ECG LVH
• X-ray Cardiac Dilatation, features of LVH
• Echocardiogram
• M mode and 2D Echo LV dilatation with severe
  AR, progressive dilatation with symptoms or left
  ventricular end systolic diametre in excess of
  5.5cm
• Pulse Vave Doppler
• Can give idea of severity by seeing how far into
  the LV cavity the AR jet reaches
• Mild AR remains within the area of AV
• Moderate AR remains between the LVOT level of
  mitral valve above papillary muscle level
• Severe AR extend to LV apex
• Continuous Wave Doppler
• The slope of deccelaration rate of the doppler
  signal of AR can give an indication of severity

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Doppler

• High velocity turbulent flow in diastole because
  of aliasing direction of flow is not seen
  correctly but dominant doppler signal are above
  the base line.

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Management

• Treatment for endocarditis
• AVR indicated if AR causes symptoms
• Vasodilators have been shown to prevent left
  ventricular dilatation
• When aortic root dilatation is cause of AR aortic
  root replacement may be necessary

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