AORTIC STENOSIS

Narrowing of the orifice of the aortic valve

AORTIC STENOSIS

Causes of Aortic Stenosis

Congenital Rheumatic fever Degenerative calcification of the aortic cusps most common Obstructive infective vegetations Pagets disease of the bone Systemic lupus erythematous Rheumatoid disease Irradiation

Congenital AS

Calcified AS

Senile or degenerative AS

Pathophysiology
Narrowed valve orifice leads to left ventricle (LV) outflow obstruction Increased LV afterload, wall stress, and myocardial oxygen demand compensatory LV hypertrophy Increased atrial contraction to maintain stoke volume Eventually heart cannot meet increased demand decreased stroke volume, cardiac output, heart failure As stenosis increases aortic/mitral regurgitation may develop

Symptoms of Aortic Stenosis

AS is asymptomatic until the valve orifice has narrowed to approximately 0.5 cm/m body surface area of adults Patients remain asymptomatic for a long period of time The condition is first diagnosed based on detection of a systolic murmur on auscultation that can be explained by the gradual process of obstruction

 Decreased exercise tolerance and dyspnea on exertion are most common symptoms Signs of pulmonary edema Systolic murmur LV hypertrophy Systolic murmur S4 is common and reflects increased atrial contribution to ventricular filling

Three Cardinal Symptoms of AS

Exertional dyspnea Exertional angina Exertional syncope

Imaging Studies
ECG Chest radiography Echocardiography Dobutamine echocardiography Cardiac catheterization

Grading of Aortic Stenosis

The aortic valve area must be reduced to onefourth of its normal size before significant changes in the circulation occur AS is graded based on the aortic valve area
Mild - >1.5 cm Moderate 1.1 to 1.5 cm Severe - <0.75 to 1 cm

Pharmacological Management
Medical treatment has no role in preventing the progression of the disease process But with the onset of LV systolic dysfunction, the use of inotropic agent may be advocated Antibiotic prophylaxis is NOT recommended in all pts. with AS for prevention of infective endocarditis. Pts. with associated systemic HTN should be treated cautiously with appropriate antihypertensive (preload dependence)

Surgical Management
AVR is indicated for symptomatic patients 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

Aortic Valve Surgery

Options include:
AVR with mechanical or bioprosthetic valve AVR with allograft (homograft) Pulmonic vavle autotransplantation (Ross) Aortic valve repair LV to descending aorta shunt

Types of AVR

Examples of replacement aortic valves: a) shows an aortic homograft, b) and c) show a xenograft, d) shows a ball and cage valve, e) shows a tilting-disk valve, f) shows a bi-leaflet valve

Balloon Valvuloplasty
Follow-up has demonstrated a high rate of restenosis (>60% at 6 months and nearly 100% at 2 years), with no decrease in mortality rate after procedure Therefore, now only has a role in critically ill elderly pts who are not candidates for surgery or as a bridge in critically ill pts before AV replacement

 Assist the patient in ADLs, if necessary. Provide a bedside commode Offer diversional activities that are physically undemanding Alternate periods of rest to prevent extreme fatigue and dyspnea. To reduce anxiety, allow the patient to express his concerns about the effects of activity restrictions on his responsibilities and routine. Keep the patients legs elevated while he sits in a chair to improve venous return in the heart. Place the patient in an upright position to relieve dyspnea.

Nursing Interventions

 Administer oxygen as needed to prevent tissue hypoxia. Keep the patient in a low sodium diet. Consult with a dietitian to ensure that the patient receives foods that he likes while adhering to the diet restrictions. Allow the patient to express his fears and concerns about the disorder, its impact on his life, and any impending surgery. Monitor the patients vital signs, weight, and intake and output for signs of fluid overload.

 Evaluate patients activity tolerance and degree of fatigue. Monitor the patient for chest pain that may indicate cardiac ischemia. Regularly assess the patients cardiopulmonary function. Observe the patient for complications and adverse reactions to drug therapy.