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• Symptoms indicate higher mortality and indication for surgery
• Change in symptoms or exam indicate need to repeat echocardiography to assess progression of
• Use caution using traditional CAD and heart failure medications in patients with severe aortic
• Epidemiology, causes, and associations
o Most common valve lesion in U.S. due to congenital biscuspid and aging population
- Bicuspid valve (1-2%)
o Other causes / associations
- Pseudoxanthoma elasticum
- Hyperparathyroidism, Paget’s, calciphylaxis
- Gaucher, Fabry’s, alkaptonuria
- Drug induced
- Carcinoid heart disease
o Other associated phenomenon
- Heyde’s: gastrointestinal angiodysplasia leading to GI bleeding Æ now thought due to …
- Type 2A von Willebrand syndrome: shear forces lead to structural changes in vWF,
rendering it more sensitive to cleavage by protease (ADAMTS-13)
• Physical exam – beyond the murmur
o Carotid parvus et tardus
o Sustained PMI – displaced only later in disease with heart failure
o Palpable S4
o S2 soft and single (A2 delayed)
o Later peaking with more severe stenosis
o Numerical estimates of severity
- Valve area: normal 3-4cm2, mild >1.5cm2, moderate 1.0-1.5 cm2, severe <1.0cm2, critical
- Gradient: moderate >20mmHg, severe >50mmHg
- Aortic-jet velocity >4m/sec on Doppler echocardiography
o Following patients with mild to mode