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Aortic stenosis / Aortic valve disease : Pathophysiology Usmle step 1
Aortic stenosis is narrowing of the aortic valve due to calcification of the valve leaflets or valvular damage.
Aortic stenosis commonly occurs at an early age in patients with congenital bicuspid aortic valves.
The most common cause of aortic stenosis is calcification of the valve leaflets with age, with the prevalence of aortic stenosis increasing rapidly beginning in the 7th decade.
Aortic stenosis can also result from rheumatic fever. Though rheumatic fever is most strongly associated with mitral stenosis, other valves may also be affected.
Aortic stenosis is classically associated with syncope, chest pain and dyspnea on exertion. Aortic stenosis can progress rapidly, leading to sudden cardiac death.
Aortic stenosis can lead to left ventricular hypertrophy as the myocardium contracts against the narrowed valve opening. The myocardium outgrows its blood supply, leading to ischemia, progressively worsening chest pain, and dyspnea from pulmonary congestion.
Since aortic stenosis leads to myocardial ischemia and a fixed cardiac output, symptoms initially present during exercise. As the disease progresses, however, symptoms begin to occur at rest.
Aortic stenosis causes a pansystolic crescendo-decrescendo murmur heard loudest in the second intercostal space at the right sternal border.
The murmur often radiates to the carotid arteries.
The murmur decreases in intensity with decreased preload (such as in the Valsalva maneuver).
Aortic stenosis is associated with an S4 heart sound as well as “pulsus parvus et tardus,” or peripheral pulses that occur weak and late relative to the heartbeat, due to the slow emptying of left ventricle to the systemic circulation.
CXR shows left ventricular hypertrophy.
Echocardiography shows a narrowed valve area with increased transvalvular pressure gradient. Other findings may include left atrial enlargement and left bundle branch block. The most accurate way to quantify the transvalvular pressure gradient is with cardiac catheterization. aortic stenosis pathology
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