Makindo Medical Notes

🫀 Aortic Stenosis (AS) = progressive narrowing of the aortic valve, causing obstruction to LV outflow. 💡 Most common valvular lesion in the UK, particularly in elderly men. ⏳ Once symptoms develop, untreated AS carries a poor prognosis (average survival 2–3 years).

📖 About

• Obstructive lesion at the level of the aortic valve.
• Prevalence: ~3% of people >75 years.
• In developed countries: calcific degeneration is the most common cause.
• In low-income countries: rheumatic disease still important.

🫀 Anatomy

• Normal aortic valve has 3 cusps: Left coronary (L), Right coronary (R), Non-coronary (N).
• Above them lie the sinuses of Valsalva, filling coronary arteries during diastole.

🔬 Pathology

• Calcific (degenerative) → stiffened, thickened cusps; commonest >70 years.
• Bicuspid valve → congenital; earlier presentation (40–60s); accelerates calcification.
• Rheumatic → leaflet fusion + commissural scarring; often coexists with AR or MS.
• Mimics: subvalvular (HOCM, membrane), supravalvular (Williams syndrome).

⚠️ Causes

🩺 Clinical Presentation

• Classic triad → Angina 💔, Syncope 💫, Dyspnoea 🫁.
• Murmur: harsh ejection systolic, best at right upper sternal edge, radiating to carotids.
• Pulses: slow-rising + narrow pulse pressure (pulsus parvus et tardus).
• Heaving, non-displaced apex beat (pressure overload).
• Late: LV dilatation → displaced apex, heart failure.

📉 Complications

• LV failure, pulmonary oedema.
• Arrhythmias, sudden cardiac death ⚡.
• Stokes–Adams attacks (arrhythmic syncope).
• Endocarditis risk.

🧪 Investigations

• Bloods: FBC, U&E, CRP, LFTs (esp. if considering endocarditis or TAVI work-up).
• ECG: LVH with strain (deep S in V1 + tall R in V5/6; lateral ST depression/T-wave inversion).
• CXR: LV enlargement, post-stenotic dilatation of ascending aorta, ± calcified valve.
• Echocardiogram = gold standard:
  • Severe AS: AVA <1.0 cm²; Mean gradient >40 mmHg; Vmax >4.0 m/s.
  • Moderate AS: AVA 1.0–1.5 cm²; Mean gradient 25–40 mmHg.
  • Mild AS: AVA >1.5 cm²; Gradient <25 mmHg.

⚡ Management Overview

• 👀 Watchful waiting: for asymptomatic mild/moderate AS. Annual echo + educate about red-flag symptoms.
• 💊 Medical therapy: not disease-modifying. – Diuretics for fluid overload (caution – preload dependent). – Treat coexistent HTN, IHD, AF. – Statins ❌ do not slow AS progression.
• 🔪 Surgical Aortic Valve Replacement (SAVR): gold standard. – Indicated in symptomatic severe AS or asymptomatic with LVEF <50% or undergoing CABG/other valve surgery.
• 🩻 TAVI/TAVR: less invasive, for older patients or those at high surgical risk.
• 🎈 Balloon Valvuloplasty (BAV): temporary bridge/palliative option; restenosis common within 6–12 months.

🧾 Surgical Indications (ESC/NICE)

• Symptomatic severe AS (angina, syncope, dyspnoea).
• Asymptomatic severe AS with:
  • LVEF <50%.
  • Very severe AS (Vmax ≥5.0 m/s).
  • Planned other cardiac surgery.

🏥 Postoperative & Long-Term Care

• Mechanical valve: lifelong anticoagulation (INR 2.5–3.5), durable.
• Bioprosthetic valve: no lifelong anticoagulation, lifespan 10–15 years.
• Ross procedure: pulmonary autograft used in selected young patients.
• Endocarditis prophylaxis before high-risk dental work if prosthetic valve.
• Lifelong echo follow-up.

📊 Prognosis

• Untreated severe symptomatic AS → survival only 2–3 years.
• Timely SAVR/TAVI restores near-normal life expectancy if performed before irreversible LV dysfunction.

📚 References

• 2017 ESC/EACTS Guidelines
• NICE NG208: Heart Valve Disease (2021)