Aortic Stenosis

Case Presentation:

In our Morning Report at WCH, we discussed a case of a patient presenting with exertional shortness of breath of three months duration. Clinical assessment and investigations were compatible with a diagnosis of symptomatic aortic stenosis.

Learning Points:

1)      Utility of clinical exam findings for aortic stenosis

2)      Important aspects on an echocardiogram report for aortic stenosis

3)      Indications for surgical intervention in aortic stenosis

Utility of clinical exam findings:

Features that can help rule in aortic stenosis (aka: high specificity):

  • Pulsus parvus et tardus
  • Decreased S2
  • Brachioradial delay
  • Apical carotid delay
  • Mid-late peaking murmur

Features that can help rule out aortic stenosis (aka: high sensitivity)

  • Absence of systolic murmur
  • Lack of radiation to clavicle

What to look for on an echocardiogram report:

Looking for features compatible with severe aortic stenosis

Parameter Threshold Value
Mean Pressure Gradient >40 mm Hg
Vmax (maximum aortic velocity) >4 m/s
Aortic valve area <1.0 cm2
LV function <50%

Surgical Indications:

  • Symptomatic aortic stenosis
  • Asymptomatic aortic stenosis with impaired LV function (<50%)
  • Asymptomatic but severe aortic stenosis (Vmax>5 m/s or Mean gradient>60 mm Hg)
  • Asymptomatic but reduced exercise tolerance or blood pressure drop with exercise
  • Undergoing other cardiac surgery with severe AoS (Class I recommendation) or moderate AoS (Class IIa recommendation)

References:

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