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Does my patient with aortic stenosis need surgery?

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The decision to refer a patient with aortic stenosis (AS) for surgery is based on the presence of symptoms, severity of AS, left ventricular function, and whether they require other surgeries involving the heart.

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HPI: Dyspnea with exertion, angina, syncope, or orthopnea. Sometimes patients adjust there lifestyle subconsciously to avoid exertion.

PMH: Hypertension, coronary artery disease, rheumatic fever/heart disease, hyperlipidemia.

PSH: Valve replacement, prior thoracotomy.

FH: Congenital bicuspid aortic valve.

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Mid-late peaking systolic ejection murmur with radiation to carotids, paradoxically split S2, diminished carotid upstroke, evidence of heart failure (elevated JVP, rales, S3, peripheral edema).

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Left ventricular hypertrophy with strain pattern, left axis deviation.

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Echo: Assess aortic valve area, pressure across the aortic valve, morphology (ex. Calcified or bicuspid). Assess left ventricle size and function.

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SYM = SYMptomatic (See HPI).

ASYM = ASYMptomatic.

CARD-SUR = Patient is due for CARDiac SURgery for reasons other than the aortic stenosis (ex. CABG).

MOD-AS = MODerate Aortic Stenosis by echocardiography.

SEV-AS = SEVere Aortic Stenosis by echocardiography.

LVSD = Left Ventricular Systolic Dysfunction with ejection fraction < 0.50.

FOLLOW = Clinical FOLLOW up and annual echocardiogram or sooner if symptoms develop. If a patient has severe aortic stenosis very close follow up is needed and consideration should be given for exercise stress testing to objectively determine if a patient is genuinely asymptomatic.

LG-AS = Low Gradient Aortic Stenosis. If LV function is low it is possible the LV cannot generate enough pressure to reveal the true severe gradient across the aortic valve. Consider dobutamine echo to enhance LV function. If LV function improves significantly and severe aortic stenosis is seen, refer for AVR.

AVR = Refer for Aortic Valve Replacement. If patient is due for cardiac surgery for other reasons, AVR is performed at the same time to reduce perioperative risk and need for repeat thoracotomy.

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MOD-AS + ASYM = FOLLOW

MOD-AS + ASYM + CARD-SUR = AVR

MOD-AS + SYM = AVR

MOD-AS + LVSD = LG-AS

SEV-AS + ASYM = FOLLOW

SEV-AS + ASYM + CARD-SUR = AVR

SEV-AS + ASYM + LVSD = AVR

SEV-AS + SYM = AVR

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In patients with severe symptomatic aortic stenosis the survival rate is 2 to 3 years unless AVR is performed.

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  • – The most common cause of death in asymptomatic valve disease is surgery! Use careful consideration in determining if symptoms are genuinely present and in deciding when to time surgery.

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  • – 1.0–2.0% of the population born with a bicuspid aortic valve.

  • – AVR is less beneficial in patients where low ejection fraction is caused by depressed contractility compared to increased afterload. Left ventricular function may be evaluated with a dobutamine echocardiogram, which will also rule out possibility of pseudo aortic stenosis.

  • – Mild aortic regurgitation present in ...

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