A Surgical Patient - National Heart Centre Singapore · A Suitable Surgical Patient – Aortic...

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A Suitable Surgical Patient – Aortic Stenosis Dr Lohendran Baskaran Cardiology Registrar NHCS

Transcript of A Surgical Patient - National Heart Centre Singapore · A Suitable Surgical Patient – Aortic...

Page 1: A Surgical Patient - National Heart Centre Singapore · A Suitable Surgical Patient – Aortic Stenosis Dr Lohendran Baskaran ... O/E: S1 + S2 ESM in aortic area radiating to R carotid.

A Suitable Surgical Patient – Aortic Stenosis

Dr Lohendran BaskaranCardiology RegistrarNHCS

Page 2: A Surgical Patient - National Heart Centre Singapore · A Suitable Surgical Patient – Aortic Stenosis Dr Lohendran Baskaran ... O/E: S1 + S2 ESM in aortic area radiating to R carotid.

Aortic Stenosis - Aetiology

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Most common valvular heart diseaseCommonest causes are:

Degenerative Calcific

Rheumatic Bicuspid Congenital

Rarer:

Paget’s , Fabry’s, irradiation,

Page 3: A Surgical Patient - National Heart Centre Singapore · A Suitable Surgical Patient – Aortic Stenosis Dr Lohendran Baskaran ... O/E: S1 + S2 ESM in aortic area radiating to R carotid.

Aortic stenosis – symptoms and signs

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Exertional anginaExertional dyspnoeaExertional dizziness/lightheadedness

Leading to

Chest pain, heart failure and syncope

Page 4: A Surgical Patient - National Heart Centre Singapore · A Suitable Surgical Patient – Aortic Stenosis Dr Lohendran Baskaran ... O/E: S1 + S2 ESM in aortic area radiating to R carotid.

Aortic stenosis – signs and symptoms

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O/E:Pulsus parvus et tardusNarrowed pulse pressureHeaving apex Auscultation:ESM aortic area radiating to carotidsCan be heard in the apex (Gallavardin phenomenon)Soft S2Paradoxical splitting (P2 precedes, comes closer to A2 in inspiration)S4The more severe, the longer and later peaking the murmur.Accentuated with squatting

Page 5: A Surgical Patient - National Heart Centre Singapore · A Suitable Surgical Patient – Aortic Stenosis Dr Lohendran Baskaran ... O/E: S1 + S2 ESM in aortic area radiating to R carotid.

Patient AB

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69-year old Chinese maleCardiac risk factors:Smoker

Type II Diabetic

Presented with some dyspnoea; NYHA II. No ankle oedema/PND/orthopnoea.No chest pain.No Syncope.

O/E: S1 + S2 ESM in aortic area radiating to R carotidSlightly heaving apex.

BP 140/70Not clinically in failure.

Page 6: A Surgical Patient - National Heart Centre Singapore · A Suitable Surgical Patient – Aortic Stenosis Dr Lohendran Baskaran ... O/E: S1 + S2 ESM in aortic area radiating to R carotid.

ECHOCARDIOGRAM

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LVEF 54%. No RWMA.Concentric LVH.Tricuspid degenerative aortic valve.Severe aortic cusp calcification.Severe aortic stenosis, MPG 56.28mmHg.AVA 0.721 cm2.AoVmax 4.7m/s

Page 7: A Surgical Patient - National Heart Centre Singapore · A Suitable Surgical Patient – Aortic Stenosis Dr Lohendran Baskaran ... O/E: S1 + S2 ESM in aortic area radiating to R carotid.

ECHOCARDIOGRAM

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Page 8: A Surgical Patient - National Heart Centre Singapore · A Suitable Surgical Patient – Aortic Stenosis Dr Lohendran Baskaran ... O/E: S1 + S2 ESM in aortic area radiating to R carotid.

Coronary angiogram

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Page 9: A Surgical Patient - National Heart Centre Singapore · A Suitable Surgical Patient – Aortic Stenosis Dr Lohendran Baskaran ... O/E: S1 + S2 ESM in aortic area radiating to R carotid.

Aortic Stenosis – Natural History

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Page 10: A Surgical Patient - National Heart Centre Singapore · A Suitable Surgical Patient – Aortic Stenosis Dr Lohendran Baskaran ... O/E: S1 + S2 ESM in aortic area radiating to R carotid.

Aortic stenosis -intervention

Page 11: A Surgical Patient - National Heart Centre Singapore · A Suitable Surgical Patient – Aortic Stenosis Dr Lohendran Baskaran ... O/E: S1 + S2 ESM in aortic area radiating to R carotid.

Aortic Stenosis – Natural History

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Page 12: A Surgical Patient - National Heart Centre Singapore · A Suitable Surgical Patient – Aortic Stenosis Dr Lohendran Baskaran ... O/E: S1 + S2 ESM in aortic area radiating to R carotid.

ESC Indications for Surgery in Aortic Stenosis

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ESC Guidelines

Guidelines on the management of valvularheart diseaseThe Task Force on the Management of Valvular Heart Diseaseof the European Society of Cardiology

European Heart Journal (2007) 28, 230–268doi:10.1093/ eurheart j / ehl428

Page 13: A Surgical Patient - National Heart Centre Singapore · A Suitable Surgical Patient – Aortic Stenosis Dr Lohendran Baskaran ... O/E: S1 + S2 ESM in aortic area radiating to R carotid.

Treatment and progress

Started on beta-blockersPlanned for elective AVR – decided on bioprosthetic valve.Had coronary angiography done, which showed mid LAD disease 70%.Hence had AVR with CABG – LIMA to LAD. Asymptomatic and well since then.