Is a result of elevation of the pulmonary capillary pressure secondary to reduced compliance and/or LV dilatation
Usually develops later and reflects an imbalance between the augmented myocardial oxygen requirements and reduced oxygen availability
Caused by arrhythmias (usually ventricular tachycardia and bradycardias), hypotension, or decreased cerebral perfusion resulting from increased blood flow to exercising muscles without compensatory increase in cardiac output
LV hypertrophy – classic finding
Other nonspecific changes are left atrial enlargement, left axis deviation, and left bundle-branch block
Not a reliable test because of the wide variations seen in AS and other cardiac conditions
ECG – LV Hypertrophy
Large S wave in V1
Large R wave in V5
Normal or enlarged cardiac silhouette
Calcification of aortic valve
Dilatation and calcification of ascending aorta
Useful in assessing the severity of AS, the degree of coexisting aortic regurgitation, LV size and function
Helpful in estimating pulmonary systolic pressure and in identifying other cardiac abnormalities
TEE – displays the obstructive orifice extremely well
Indicated in patients with moderate aortic stenosis and LV dysfunction to predict the reversibility of LV dysfunction after AVR
Pts. With AS, LV dysfunction, and relatively low gradients have better outcome when management decisions are based on the results of dobutamine echocardiogram (Schwammenthal, et al, 2001)
Indicated for hemodynamic evaluation whenever there is discrepancy between the clinical picture and echocardiography
AVR improves survival in patients with depressed as well as normal LV function
The risks of surgery and prosthetic valve complications outweigh the benefits of preventing sudden cardiac death and prolonged survival in asymptomatic patient
Types of Valves
Mechanical (St. Jude)
Bioprosthesis vs. Mechanical Valves
Bioprosthesis valves are less durable than mechanical valves and begin to deteriorate after 5-6 years; usually do not require long-term coagulation
Mechanical valves are durable but require lifelong anticoagulation to control thromboembolism
Mechanical valve was associated with significantly lower 15 year mortality compared with bioprosthesis valve (66% vs. 79%) (Hammermeister, et al, 2000).
Mechanical valves are less obstructive than stented bioprosthesis valves of the same size (Bech-Hanssen, et al, 1999).
Despite a better survival rate with mechanical valve, the choice of valve should be tailored to the patient’s needs.
Alpert, J. T. (Ed.). (2001). The AHA Clinical Cardiac Consult. Philadelphia: Lippincott Williams & Wilkens.
Bech- Hassen, O., Caidahl, K., Wall, B., Myken, P., Lason, S., & Wallentin, I. (1999). Influence of aortic valve replacement, prosthesis type, and size of functional outcome and ventricular mass in patients with aortic stenosis. Journal of Thoracic Cardiovascular Surgery. 118(1):57-65.
Braunwald, E., Fauci, A. S., Kasper, D. L., Hauser, S. L., Longo, D. L., & Jameson, J. L. (2001). Harrison’s 15th Edition Principles of Internal Medicine. New York: McGraw-Hill.
Hammersmeister, K., Sethi, G. K., Henderson, W. G., Grover, F. L., Oprian, C., & Rahimtoola, S. H. (2000). Outcome 15 years after valve replacement with a mechanical versus a bioprosthetic valve: Final report of the Veterans Affairs Ramdomized trials. Journal of American Cardiology. 36:1152-1158.
Martin, L. & Coulden, R. (1999).Cardiac radiology: valvular heart disease. Clinics of North America. 37(2):319-338.
Munt, B. (1999). Physical examination in valvular aortic stenosis: correlation with stenosis severity and prediction of clinical outcome. American Heart Journal. 137(2):298-306.
Nowrangi, S. K., Connolly, H. M., Freeman, W. K., & Click, R. L. (2001). Impact of intraoperative transesophageal echocardiography among patients undergoing aortic valve replacement for aortic stenosis. Journal of American Society of Echocardiography. 14(9):863-6.
Otto, C. M. (1999). Valvular Heart Disease. Philadelphia: W. B. Saunders Company.
Tierney, Jr., L. M., McPhee, S. J., & Papadakis, M. A. (2002). Current Medical Diagnosis & Treatment: 2002. (41st Ed.). New York: Lange Medical Books/McGraw-Hill.