AS & ARAbdelrahman Al-daqqa

• The most frequent valvular heart disease (~25%)• The most frequent cardiovascular disease after

hypertension and coronary artery disease in Europe and North America.

• Aortic stenosis is present in 1.3% of people aged 65–74 years and in 4% of people older than 85 years of age

• Aortic sclerosis; A degenerative disease of the aortic valve most likely represents an early stage of aortic stenosis. (> 65 years ~ 30%)

Aortic Stenosis - Prevalence

Symptoms

signs

• systolic, crescendo-decrescendo (i.e., 'ejection') murmur.

• pulsus parvus et tardus• Soft S2• S4• Precordial thrill• Sustained PMI

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease

AR

Epidemiology

The prevalence of AR varied with age and disease severity. More than trace AR was unusual before age 50 and then increased progressively.

●For mild AR, the prevalence was 3.7, 12.1, and 12.2 percent in men at ages 50 to 59, 60 to 69, and 70 to 83, respectively. The comparable values in women were 1.9, 6.0, and 14.6 percent.

Aortic Regurgitation:Etiology

• Any conditions resulting in incompetent aortic leaflets• Congenital

– Bicuspid valve• Aortopathy

– Cystic medial necrosis– Collagen disorders (e.g. Marfan’s)– Ehler-Danlos– Osteogenesis imperfecta– Pseudoxanthoma elasticum

• Acquired– Rheumatic heart disease– Dilated aorta (e.g. hypertension..)– Degenerative– Connective tissue disorders

• E.g. ankylosing spondylitis, rheumatoid arthritis, Reiter’s syndrome, Giant-cell arteritis )

– Syphilis (chronic aortitis)• Acute AI: aortic dissection, infective endocarditis, trauma

Aortic Regurgitation:Symptoms

• Dyspnea, orthopnea, PND• Chest pain.– Nocturnal angina >> exertional angina – ( diastolic aortic pressure and increased LVEDP thus

coronary artery diastolic flow)• With extreme reductions in diastolic pressures (e.g. <

40) may see angina

Peripheral Signs of Severe Aortic Regurgitation

• Quincke’s sign: capillary pulsation• Corrigan’s sign: water hammer pulse• Bisferiens pulse • De Musset’s sign: systolic head bobbing • Mueller’s sign: systolic pulsation of uvula

• Durosier’s sign: femoral bruits• Traube’s sign: pistol shot femorals• Hill’s sign:BP Lower extremity >BP Upper extremity by

– > 20 mm Hg - mild AR– > 40 mm Hg – mod AR– > 60 mm Hg – severe AR

Wave Sound

Aortic Regurgitation: Physical Exam

• Widened pulse pressure – Systolic – diastolic = pulse pressure

• High pitched, blowing, decrescendo diastolic murmur at LSB

• Best heard at end-expiration & leaning forward• Hands & Knee position

Central Signs of Severe Aortic Regurgitation

• Apex:– Enlarged– Displaced– Hyper-dynamic– Palpable S3 – Austin-Flint murmur

• Aortic diastolic murmur– length correlates with severity (chronic AR)

Treatment• The ACC/AHA guidelines > vasodilator therapy.• The 2012 European Society of Cardiology (ESC)/European

Association for Cardio-Thoracic Surgery (EACTS) guidelines recommend short-term use of vasodilators and inotropic agents to improve the condition of patients with severe heart failure before proceeding with valve surgery.

• Antibiotic Prophylaxis :under current ACC/AHA guidelines, the prophylactic use of antibiotics prior to dental procedures is no longer routinely recommended for all patients with AR.

2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease