University

ofGalway.ie
Reminder
o PLEASE keep practicing your CVS exam – it is the only way to become more comfortable with
murmurs, volume assessment, device placement etc.
o Ensure you are palpating a pulse when listening to heart sounds – ideally a central pulse (i.e.
the carotid).
o Listen to murmurs on youtube, or mannequins are available to practice on from the medical
school
Our Case
o Joe, 70-year-old man, is referred to the emergency department of University Hospital Galway,
complaining of progressive shortness of breath on exertion. He first noticed this about 6 months ago,
but it has been getting steadily worse since then. He first noticed that he was becoming a bit more
short of breath after his daily 2 mile walk, but now he is unable to keep up with his wife. He becomes
short of breath after about 100 meters and has to talk a break for a few minutes. He has also noted
some dizziness on getting up suddenly or when he walks faster than he normally would. He denies
chest pain put has noted some “heaviness” occasionally when he gets short of breath. He also
sometimes feels a bit sweaty when this happens. He has never had these symptoms while at rest. He
does have a non-productive cough, but he says “sure I’ve had that since I was in my 50’s!”

o He denies any chest pain or shortness of breath currently

 Joe, 70 year old male

Past medical history Family history Medications (NKDA) Social history

§ Hypertension § He lives at home with his wife,
§ Father RIP aged § Aspirin 75mg OD PO Carole. They will be
§ Hypercholesterolemia 85 colorectal ca celebrating their 52nd wedding
§ Atorvastatin 40mg OD anniversary this July. They
§ Benign prostatic hypertrophy PO have 3 grown children.
§ Mother RIP
§ Stage 3 chronic kidney aged 90 § Has smoked cigarettes on
disease § Ramipril 2.5mg OD PO and off all of his life. Currently
following CVA smokes about 10 cigarettes a
§ Peripheral arterial disease – § Spiriva (tiotropium day but used to smoke up to 2
intermittent claudication bromide) 2.5mcg inhaled packs. He also occasionally
smokes a pipe.
§ His GP recently started him OD
on a trial of an inhaler – Spiriva § He drinks 3 or 4 pints of
(tiotropium bromide) Guinness every weekend
 On examination General inspection à Alert and orientated to person,
place and time

• RR 17,
• Sats 93% RA,
• BP142/90,
• HR 88bpm,
• Temp 36.8°C
Soft second heart sound. When going to SNT
grade 3 ejection systolic auscultate his lungs BS+
murmur in the right second you note a diffuse
intercostal space. It radiates wheeze throughout
throughout the precordium both lung fields but
and to both carotids otherwise there are no
added sounds
New Murmur

No murmur documented Ejection systolic Right second intercostal

previously space, radiating to
carotids
Based on the information provided, suggest FOUR possible differential diagnoses that
may be contributing to Joe’s shortness of breath on exertion. Justify each answer you
provide?
Pulmonary causes of SOB
 Pulmonary
Cardiac causes
causes of of SOB of SOB
SOB causes
GI/Neuro/other causes of SOB
Suggest THREE potential differentials for a systolic murmur. For
each answer you provide, suggest a clinical manoeuvre that
will help you differentiate between your answers?
The diagnosis here - Aortic Stenosis
Causes

Risk Factors

Differentials

Mortality

Investigations

Management
Symptoms of AS

Syncope Angina Dyspnoea

 Aetiology
Congenital
o Unicuspid
o Bicuspid
o Supravalvular aortic
membrane

Acquired
Top 4 - >95% of AS
o Calcific aortic disease o Calcific aortic disease
(formerly known as
degenerative valve o Bicuspid aortic valve
disease) o Rheumatic Heart Disease
oRheumatic valve heart o Supravalvular aortic membrane
disease
Calcific Aortic Valve Disease
o Aortic sclerosis and aortic stenosis are both included in this term (previously known as
“degenerative” valve disease)
o Was thought to be an inevitable process of aging. Not just “wear and tear”. Active process with
inflammation, lipoprotein deposition, RAAS activation, active calcification with potential
genetic/valve predisposition.
Bicuspid Aortic Stenosis
• Estimated prevalence of 1-2%
• 3 times more common in males than
females
• If you have a first degree relative with a
bicuspid valve there is a 10% chance that
you will inherit it
• Associated with:
• Ejection systolic click
• Dilatation of the thoracic aorta
• Coarctation in up to 20% of cases
• Interestingly, most patients with BAV disease
have a left dominant coronary circulation

Young patient? Think of a bicuspid valve

Mordi, I. & Tzemos, N. Bicuspid aortic valve disease: a comprehensive review. Cardiol.
Res. Pract. 2012, 196037–196037 (2012)
Risk Factors
1. Older age
2. Bicuspid aortic valve
3. Metabolic syndromes
• Dyslipidaemia
• Obesity
• Diabetes

4. Hypertension
5. Chronic kidney disease
Aortic stenosis vs Mitral regurgitation
Aortic Stenosis Mitra Regurgitation
Loudest in aortic area Loudest at apex
Radiates to carotids Radiates to axilla
Ejection systolic (At the beginning of systole) Pan systolic (i.e. throughout systole)
No positioning will increase murmur Louder when patient rolled onto left lateral
decubitus position
Louder on expiration (as with all left sided valve Louder on expiration
lesion)
Aortic Sclerosis
o Aortic valve thickening and calcification without a significant pressure gradient
o 25% of people over 65 will have evidence of sclerosis
o Progresses to stenosis at a rate of about 1.8-1.9% per year
o Associated with an increased risk of cardiovascular events
o Approximately 50% increased risk of cardiovascular events
Aortic Sclerosis Aortic Stenosis

Normal s2 In severe AS – diminished s2

Normal pulse Slow rising, reduced amplitude

No radiation to carotids Radiates to carotids

Normal pulse pressure Narrow pulse pressure

How would you differentiate aortic stenosis from HOCM?

Aortic stenosis vs HOCM
o Both may present with syncope
o Both present with harsh ejection systolic murmurs radiating to the carotids

o Murmur will get LOUDER in HOCM with Valsalva manoeuvre

o Murmur will be UNCHANGED in AS with Valsalva manoeuvre

o Murmur will get LOUDER on deep expiration with Aortic Stenosis

o Murmur will be UNCHANGED on deep expiration with HOCM
 Typical progression
of AS (untreated)
o Multiple predictors of poor outcome:
o Older age
o Atherosclerotic risk factors
o Echo: rate of progression, excessive LVH, increased
gradient with exercise, P-HTN
o EST: unmasking of symptoms during exercise, abnormal
BP response, ST depression
o Elevated plasma levels of natriuretic peptides

o Below based on Framingham study (which is old!!)

o Angina: 5 years
o Syncope: 3 years
o Dyspnoea: 2 years
What features have been identified on Joe’s clinical examination would suggest
severe aortic stenosis?
 Severe AS on clinical exam
o Low volume, slow rising pulse
o Narrow pulse pressure
o Heaving apex beat
o Systolic thrill
o Soft or absent S2
o Late systolic peaking of the murmur
o Signs of heart failure – what are these?
o S4
Joe goes on to have a 12 lead ECG – describe the findings…
Questions
Other than an ECG and
troponin, suggest 3 other
investigations you would
order in the emergency
department. Justify each
investigation.
Investigations – suspected valvular heart disease
Bedside
ECG - ?LVH Radiology/other
CXR – ?cardiomegaly,
Blood pressure – lying and standing evidence of heart failure
Lab ?evidence of infection
FBC – Hb anaemia can cause all symptoms of AS. Anaemia is also a common
finding in AS. ?Syndrome of low Hb, severe AS and angiodysplasia Transthoracic Echo –
Venous blood gas – PH, lactate, glucose and quick turnaround for K and Na What are we looking for
on echo?
Renal profile – Need contrast in angiogram. You will need to know renal
function for meds such as ACE-I. Also K abnormalities can precipitate
arrhythmias.
Liver function tests – May we be starting a statin
High sensitivity cardiac troponins
BNP (or NT – pro BNP) – if suspect or known heart failure
Coag screen
Investigations
Transthoracic echocardiography is the key
diagnostic tool.
o Confirms the presence of aortic stenosis;
assesses the degree of valve calcification, LV
function and wall thickness; detects the
presence of other associated valve disease or
aortic pathology and provides prognostic
information.
Joe is managed appropriately in the emergency department and is transferred to the ward for further
investigations and management. On day 2 of admission, he goes on to have an echocardiogram. This
shows an ejection fraction of 55%. Among other things, you note that the aortic valve area is 0.8cm2
with a mean pressure gradient of 60mmHg across his aortic valve.

How would you classify Joe’s Aortic Stenosis

Severe AS
∆Pm (pressure
gradient) =
60mmHg

Vmax (velocity) =
?m/s

AVA(valve surface
area) = 0.8cm2
What are some of the complications associated with severe untreated aortic stenosis?
Question - What is the definitive management for this
patient? Justify your answer
Complications of aortic stenosis
1. Left ventricular failure
2. Sudden death
3. Pulmonary hypertension
4. Arrhythmias
5. Heart block (calcification of the conduction system)
6. Infective endocarditis
7. Iron deficiency anaemia

What is Heydes Syndrome?

Heydes
Syndrome
1. Aortic stenosis
2. Acquired coagulopathy
(von Willebrand
syndrome)
3. Intestinal bleeding from
angiodysplasia (anaemia
due to same)

VWF circulates as large

multimers
VWF passes across the valves
the shear stress across the
disease valve causes
degradation
Cured by AVR
What are the management options available to Joe ?
Question - What is the definitive management for this
patient? Justify your answer
Management Options

MEDICAL SURGICAL
Medical Management
• No medical therapy improves outcomes in severe AS

• Patients with co-existing HF should be treated by latest guidelines, Beta

blockers can be helpful. Avoid nitrates or other drugs which would worsen
postural drops

• Hypertension should be treated, but hypotension should be avoided

• Maintenance of sinus rhythm is crucial

Indications for intervention on valve
1. AS Intervention is recommended in symptomatic patients with severe, high-gradient aortic
stenosis (mean gradient >40 mmHg, peak velocity >4.0 m/s and valve area <1.0 cm2)
2. Intervention should be considered in asymptomatic patients with severe aortic stenosis and
systolic LV dysfunction (LVEF <55%) without another cause (new to guidelines)
3. Severe Aortic Stenosis regardless of symptoms in patients undergoing CABG or other valve
surgery
4. Intervention should be considered in asymptomatic patients with LVEF >55% and a normal
exercise test if the procedural risk is low and one of the following parameters is present: very
severe stenosis, severe valve calcification, markedly elevated BNP
Definitive Treatment
=
New Valve
Surgical Management

Surgical Aortic TAVR/I

Valve (transcatheter aortic
Replacement valve replacement)
Advantages/disadvantages
Surgical Valve replacement
Advantage
Longer lasting/more durable
Can treat active/suspected
endocarditis
Suitable for those with bicuspid
aortic valve
If person has triple vessel disease
– can do CABG simultaneously
Disadvantage
Will require lifelong warfarin (if
mechanical)
Potential complications of surgery
– would dehiscence, AKI,
prolonged hospitalisation,
infection
Could be challenging if
sternotomy done previously
TAVI/TAVR
Advantage
Can be done in those not fit for
surgery – higher surgical risk
Less risk of peri-procedural MI,
stroke, blood loss, AKI
Does not require anticoagulation
Disadvantage
Theoretically may not be as
durable as surgical repair
Can cause peri-procedural heart
block – requires pacemaker
Joe is keen for intervention. Use the Euroscore II (http://www.euroscore.org/calc.html) to estimate Joe’s peri-operative
Question - What is the definitive management for this
mortality. Assume that his coronary arteries have no significant narrowing’s and that he would only require an isolated aortic
valve replacement. His weight is 80kg
patient? Justify your answer
http://www.euroscore.org/calc.html
Surgical Management
ESC guidelines “The choice between surgical and
transcatheter intervention must be based upon careful
Surgical Aortic TAVR/I
evaluation of clinical, anatomical and procedural
factors by the Heart Team, weighing the risks and
Valve
benefits of each approach for an individual patient.
(transcatheter aortic
Replacement
The Heart Team recommendation should be discussed
valve replacement)
with the patient who can then make an informed
treat- ment choice”
 SAVR is recommended in:
TAVI is recommended in:
• Younger patients <75 years
• Older patients (>_75 years),
• Those who are low risk for surgery (STS- PROM/
• Those who are high-risk (STS-PROM/ EuroSCORE II >8%) or
EuroSCORE II <4%) or
• Unsuitable for surgery.
• in patients who are operable and unsuitable for
transfemoral TAVI.

SAVR or TAVI are recommended for remaining patients according to

individual clinical, anatomical and procedural characteristics….
Clinical, anatomical and procedural factors that influence the choice
of treatment modality for an individual patient (1)
Favours Favours
TAVI SAVR
Clinical characteristics
Lower surgical risk - +
Higher surgical risk + -
Younger age - +
Older age + -
Previous cardiac surgery (particularly intact coronary artery bypass grafts
+ -
at risk of injury during repeat sternotomy)
Severe frailty + -

©ESC/EACTS
Active or suspected endocarditis - +

2021 ESC/EACTS Guidelines for the management of valvular heart disease

www.escardio.org/guidelines (European Heart Journal; 2021 – doi: 10.1093/eurheartj/ehab395; European Journal of Cardio-Thoracic Surgery; 2021 – doi: 10.1093/ejcts/ezab389)
Clinical, anatomical and procedural factors that influence the choice
of treatment modality for an individual patient (2)
Favours Favours
TAVI SAVR
Anatomical and procedural factors
TAVI feasible via transfemoral approach + -
Transfemoral access challenging or impossible and SAVR feasible - +
Transfemoral access challenging or impossible and SAVR inadvisable + -

Sequelae of chest radiation + -

Porcelain aorta + -
High likelihood of severe patient–prosthesis mismatch + -
(AVA <0.65 cm2/m2 BSA)

©ESC/EACTS
2021 ESC/EACTS Guidelines for the management of valvular heart disease
www.escardio.org/guidelines (European Heart Journal; 2021 – doi: 10.1093/eurheartj/ehab395; European Journal of Cardio-Thoracic Surgery; 2021 – doi: 10.1093/ejcts/ezab389)
Clinical, anatomical and procedural factors that influence the choice
of treatment modality for an individual patient (3)
Favours Favours
TAVI SAVR
Anatomical and procedural factors (continued)
Severe chest deformation or scoliosis + -
Aortic annular dimensions unsuitable for available TAVI devices - +
Bicuspid aortic valve - +
Valve morphology unfavourable for TAVI (e.g. high risk of coronary
- +
obstruction due to low coronary ostia or heavy leaflet/LVOT calcification)
Thrombus in aorta or LV - +

©ESC/EACTS
2021 ESC/EACTS Guidelines for the management of valvular heart disease
www.escardio.org/guidelines (European Heart Journal; 2021 – doi: 10.1093/eurheartj/ehab395; European Journal of Cardio-Thoracic Surgery; 2021 – doi: 10.1093/ejcts/ezab389)
Clinical, anatomical and procedural factors that influence the choice
of treatment modality for an individual patient (4)
Favours Favours
TAVI SAVR
Concomitant cardiac conditions requiring intervention
Significant multi-vessel CAD requiring surgical revascularization - +
Severe primary mitral valve disease - +
Severe tricuspid valve disease - +
Significant dilatation/aneurysm of the aortic root and/or ascending aorta - +
Septal hypertrophy requiring myectomy - +

©ESC/EACTS
2021 ESC/EACTS Guidelines for the management of valvular heart disease
www.escardio.org/guidelines (European Heart Journal; 2021 – doi: 10.1093/eurheartj/ehab395; European Journal of Cardio-Thoracic Surgery; 2021 – doi: 10.1093/ejcts/ezab389)
Following a discussion with the patient, it is decided to go ahead with a TAVI, what are the potential complications of a TAVI?
Question - What is the definitive management for this
patient? Justify your answer
 His most
Use EITHERrecent
thebloods are shown
STS Risk Scorebelow:
(http://riskcalc.sts.org/stswebriskcalc/calculate)
(beware of American units!) or Euroscore II (http://www.euroscore.org/calc.html)
to estimate Mabel’s peri-operative mortality. Refer back to her full medical history
Following
from parta1discussion withAssume
of the case. the patient, it isher
that decided to go stent
coronary ahead remains
with a TAVI, what are
patent andthe
that
potential
she wouldcomplications
only requireof an
a TAVI?
isolated aortic valve replacement

Test Value Reference

Sodium 137mmol/L 132 to 146
Potassium 3.6mmol/L 3.7 to 5.4
Urea 10.5mmol/L 2.9 to 8.2
Creatinine 160umol/L (stable) 49 to 80
eGFR (CKD-EPI) 26ml/min 60 to 160
WCC 6.8x109/L 4 to 10
Haemglobin 11g/dL 12 to 15
Haematocrit 0.38L/L (38%) 0.36 to 0.46 (36-46%)
Platelets 200x109/L 150 to 400
Complications of SAVR
Early Late
Paravalvular regurgitation Infective endocarditis
Aortic dissection Haemolysis
Stroke Thrombosis (esp. with mechanical valves)
Coronary artery dissection
ALL the risks of surgery – AKI, blood loss,
Wound dehiscence, Damage to local
structures
Complications of TAVR/I
Early Late
Bleeding Paravalvular leak (this appears to be
reducing in trials)
Aortic dissection Valve thrombosis
Ventricular perforation Valve endocarditis
Stroke (2.5 – 5%)
High degree AV block – requires
pacemaker (6%)
New afib
Following a his TAVI, Joe develops a heart block and requires a pacemaker. You have to consent him – how do you do this?
Question - What is the definitive management for this
patient? Justify your answer
 Any consent
1. What is the procedure and what it
involves

2. Risks:
1. Common
2. Uncommon
3. Rare

3. Options:
1. Having the procedure
2. Not having the procedure
3. Alternatives

4. Questions
Indications for PPM
o Sick sinus syndrome
o Symptomatic sinus bradycardia
o Tachy-brady Syndrome
o AF with sinus node dysfunction
o Complete AV block (3rd degree HB)
o Chronotropic incompetence
o Cardiac Resynchronisation Therapy – with
biventricular pacing
He has a CXR prior to going home – any problems?