CardiologyTier 1Disease (DEADMAN)

Aortic stenosis

Description

Obstruction to LV outflow at the aortic valve
Fixed afterload -> concentric LVH -> preserved stroke volume for years
- -> diastolic dysfunction -> systolic failure
Long asymptomatic latent period, then abrupt decline
- Once symptomatic, survival without intervention measured in years

Commonest valve lesion requiring intervention in developed world
Prevalence rises steeply with age - few % of adults >75
Bicuspid valve in 1-2% of population
- Presents 1-2 decades earlier than calcific trileaflet

Calcific (degenerative) - commonest in older adults
- Active process resembling atherosclerosis, not passive wear
- Lipid deposition -> inflammation -> osteoblastic differentiation -> calcification
Bicuspid valve - abnormal leaflet mechanics accelerate the same process
- Earlier onset, often with associated aortopathy
Rheumatic - commissural fusion, almost always with mitral involvement
- Uncommon in Australia outside Aboriginal and Torres Strait Islander populations

Clinical

ESM at right upper sternal edge, radiating to carotids
Slow-rising, low-volume pulse
Soft or absent A2
Severity indicated by late-peaking murmur + delayed carotid upstroke
- Murmur intensity does NOT indicate severity

TTE - diagnostic test

Low-flow low-gradient AS

Reduced EF + small valve area but low gradient
Dobutamine stress echo to separate true severe from pseudo-severe
- True severe: gradient rises with inc flow, area stays small

No medical therapy alters natural history
- Statins do NOT slow progression despite shared risk factors
Management = surveillance until intervention indicated

Intervention - when

Symptomatic severe AS
Asymptomatic severe AS with:
- LVEF <50%, OR
- Positive exercise test, OR
- Very severe (velocity >=5.0 m/s) or rapid progression

Intervention - which

Heart Team decision - age, surgical risk, anatomy, life expectancy
SAVR - younger, low risk, bicuspid, concomitant surgery needed
TAVI - older, higher risk; now extends to low surgical risk (PARTNER 3, Evolut Low Risk)
Balloon valvuloplasty - bridge only

Concurrent

Bicuspid valve -> aortopathy (root/ascending dilatation), coarctation
Heyde syndrome - severe AS + acquired von Willebrand deficiency
- -> angiodysplastic GI bleeding, resolves after valve replacement
Calcific disease shares risk factors with atherosclerosis

Asymptomatic severe AS - low but real risk of sudden death
- Greater risk is symptom onset
Once symptomatic and untreated, mortality high
- Angina -> syncope -> heart failure, in ascending order of severity

Complications

Heart failure
Arrhythmia - AF, conduction disease (calcium encroaching on conduction system)
Infective endocarditis
Heyde syndrome bleeding

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