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Aortic Stenosis

 

Thank you for asking me to perform a cardiovascular of examine Mr. X, who presented with SOB.

 

The salient finding on examination were a crescendo-decrescendo systolic murmur loudest in the aortic region, which increased on expiration and radiated to the carotids, which I believe is consistent with aortic stenosis.

 

I will now present my findings in full before commenting on differentials, aetiology, severity and complications.

 

The patient was comfortable at rest with normal/increased WOB.

 

On examination of the hands, there was/was no stigmata of IE, clubbing, peripheral cyanosis, or xanthomata.

 

The pulse was ____ and regular/irregular (if irregular, consistent with atrial fibrillation).

 

The blood pressure was ____.

 

On examination of the face, there was no scleral icterus, conjunctival pallor or, xanthelasma. There was no central cyanosis. Dentition was adequate/inadequate.

 

The JVP was/was not elevated at ___ cm above the sternal notch with normal waveforms/prominent A-wave/prominent V-wave.

 

The carotid pulse was anacrotic/plateau in character.

 

On inspection of the praecordium, there were/were not scars and nil obvious deformity.

 

On palpation, the apex beat was fifth intercostal space mid-clavicular line and pressure loaded (hyperdynamic, systolic overloaded, forceful and sustained). There were/were not any palpable thrills (systolic thrill in aortic area is sign of severity). There was/was not a left parasternal heave.

 

On auscultation, as aforementioned, there was a systolic murmur loudest in the aortic region, which increased on expiration, and radiated to the carotids. It was accentuated on sitting forward. It was softer with dynamic Valsalva and isometric maneuvers. Additionally, there was a musical pansystolic/holosystolic murmur at the apex with radiation to the axilla, which may present Gallavardin’s phenomenon or mitral regurgitation.

 

There was a normal/soft/loud/single first and second heart sound, with physiological/ reversed splitting (sometimes reversed because of delayed ejection), with no additional third or fourth heart sound/third/fourth heart sound.

 

On further examination, there was/was not evidence of left and right heart decompensation with sacral oedema or peripheral oedema, and vesicular breath sounds/bibasal inspiratory crackles. There was/was not a pulsatile liver, and nil gross ascites.

 

In summary, my findings are consistent with aortic stenosis

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Other differentials include:

  • AS + MR

  • HOCM

  • VSD

  • Mitral regurgitation

  • Tricuspid regurgitation

 

In terms of severity:

  • In terms of signs of severity, there was/was not a plateau pulse, aortic thrill, prominent intensity and harshness to the murmur and lateness of the peak, a fourth heart sound, paradoxical splitting of the second heart sound, and signs of LVF.

 

In terms of the aetiology:

  • Degenerative

  • Rheumatic

  • Bicuspid or unicuspid

 

I would proceed from here by:

  • Confirming my diagnosis with an echocardiogram

 

What is severe AS on TTE?

  • AS Jet Velocity > 4.0 m/s

  • Mean gradient > 40mmHg

  • AVA < 1.0cm^2

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What are the indications for surgery? (From UpToDate)

  • Severe AS with symptoms

  • ASx patients with severe AS and LVEF < 50%

  • ASx with 'very severe' AS (gradient > 60mmHg)

  • Severe AS ongoing other cardiac surgery

  • ASx patients with severe AS and decrease exercise tolerance or fall in blood pressure with exercise

 

Would you do a TAVI vs. SAVR (surgical AVR?)

  • If prohibitive surgery risk, then do a TAVI

  • If not prohibitive, depends on age/life expectancy, and anatomy

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