What is Aortic Stenosis (AS)
Normal area of aortic valve is 1.5–2 cm². It is severe, if the area is < 1 cm². If the valve area is <
0.7 cm², it is called critical aortic stenosis.
Causes of Aortic Stenosis
• Chronic rheumatic heart disease.
• Congenital bicuspid aortic valve (common in male).
• Calcification in old age.
• Congenital (in early age).
Symptoms
• Breathlessness, mainly on exertion.
• Palpitation.
• Anginal chest pain.
• Syncope (transient loss of consciousness) during effort.
• Sudden death (probably due to ventricular fibrillation).
Signs
• Pulse—low volume, slow rising.
• BP—low systolic, normal diastolic, narrow pulse pressure.
Precordium examination:
• Inspection:
–– Visible cardiac impulse in mitral area.
• Palpation:
–– Palpable apex beat, heaving in nature.
–– Systolic thrill in aortic area.
• Auscultation:
–– 1st heart sound—normal in all the areas.
–– 2nd heart sound—A2 is soft in all the areas, P2 is normal.May be reversed splitting of S2.
–– Ejection systolic murmur in aortic area, radiates to the neck.
Investigations
• X-ray of chest—shows enlarged heart.
• ECG shows left ventriculay hypertrophy (LVH).
• Echocardiogram, preferably colour Doppler echo.
• Cardiac catheterisation in some cases.
Complications
• Left ventricular failure.
• Infective endocarditis (10% cases).
• Sudden death due to ventricular fibrillation.
• Complete heart block (in calcification of aortic valve).
• Systemic embolism.
Signs of Severe AS
• Pulse is feeble or absent.
• Absent or soft A2 (or single S2).
• Harsh, loud, prolonged murmur with late peaking.
• Reverse splitting of second heart sound.
• Presence of fourth heart sound.
• Presence of heart failure or LVF (late sign).
Treatment
• If aymptomatic—follow-up with periodic echocardiogram. Avoid strenuous activity or exercise.
• If symptomatic or syncopal attack—valve replacement.
• If asymptomatic with severe AS—valve replacement.
• If the patient is unfit for surgery—percutaneous valvuloplasty.
• In children, elderly or pregnancy—valvotomy.
Indications of Surgery
• All symptomatic patients (such as syncope).
• If mean systolic pressure gradient is >50 mmHg (left ventricular systolic pressure > aorta).
• If the valve area is <0.7 cm2.
• Abnormal BP in response to exercise.