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Common Congenital Heart Lesions - page 12 / 126





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Stenotic Semilunar Valve Disease Aortic Stenosis (AS)

Clinical Presentation:

  • Chest pain (angina): median survival 5 years after chest pain starts

  • Syncope: median survival 3 years

  • Dyspnea on exertion (CHF): median survival 2 years

  • Atrial fibrillation (less common): median survival 6 months

  • Note: These symptoms may appear after many asymptomatic years of slowly progressing stenosis. Once the

symptoms develop, they confer decreased survival if surgical correction is not undertaken.

Physical Exam: can permit accurate detection and estimation of the severity of the AS

  • Typical findings:

    • o

      Auscultation: coarse mid-systolic ejection murmur, S4 (atrial contraction into the stiff LV), split S2 with soft A2

      • Specifics for auscultation based on severity:

      • Mild AS: ejection click, early systolic murmur, split S2

  • Moderate AS: longer systolic murmur that peaks in mid-to-late systole (no ejection click because the valves are getting older)

  • Severe AS: even later peaking systolic murmur (don’t even hear the A2 part of S2 because the valve doesn’t even close)

      • Note: If patient has AS and has an Ejection Click, that’s a good sign!!!

  • Differentials for auscultating in the three Congenital types of AS:

  • With Congenital Valvular AS: aortic ejection click paradoxically heard at the heart’s apex

  • With Subvalvular AS: aortic systolic murmur with an associated diastolic aortic regurgitation

  • With Supravalvular AS – no associated aortic regurgitation and no ejection click

    • o

      Carotids: weakened (“parvus”) & delayed, slow rising (“tardus”) upstroke, which peaks right before S2,

and decreased volume due to obstructed LV outflow [note: normal carotid pressure peaks at same time as LV pressure peaks]. Can also have shudder/thrill during contraction, which reflects turbulence in LV outflow.

      • o

        Palpation: suprasternal thrill, evidence of LVH in a sustained PMI

      • o

        Jugular Venous Pulse: “v” should be the big rise, but with AS and associated LVH, get “a” as the dominant wave. Anything that causes concentric hypertrophy can show this large “a” wave in the JV Pulse.

  • Note: In older patients, not uncommon to have murmur of calcific AS that is most audible in the mitral area. However, if you’ve appreciated the weakened, delayed carotid pulse before auscultating, you won’t miss the diagnosis of calcific AS even though it is heard in the mitral area.

    • o

      If these same older patients have Ventricular Premature Beats, you may take advantage of varying diastolic filling periods – with larger end diastolic volume, you hear a larger murmur. Regurgitant murmurs (in the differential diagnosis), however, keep the same murmur intensity regardless of the increased filling period.

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