Aortic Stenosis

AORTIC STENOSIS

Q. 1

Dicrotic nature of aortic notch is lost in?

 A Aortic Stenosis
 B

Aortic Regurgitation

 C PDA
 D

Arteriosclerosis

Q. 1

Dicrotic nature of aortic notch is lost in?

 A Aortic Stenosis
 B

Aortic Regurgitation

 C PDA
 D

Arteriosclerosis

Ans. A

Explanation:

Aortic Stenosis REF: Harrison’s 17th ed chapter 220

Anacrotic pulse with a slow initial upstroke, the peak is close to S2; these features suggest fixed left ventricular outflow obstruction, such as occurs with valvular aortic stenosis


Q. 2

Which of the following is not a common manifestation of congenital Rubella?

 A

Deafness

 B

PDA

 C

Aortic stenosis

 D

Mental retardation

Q. 2

Which of the following is not a common manifestation of congenital Rubella?

 A

Deafness

 B

PDA

 C

Aortic stenosis

 D

Mental retardation

Ans. C

Explanation:

Most common finding of congenital Rubella is IUGR. Other manifestations are cataract, PDA, Pulmonary stenosis, sensorineural hearing loss meningoencephalitis, pneumonia, hepatitis, bone lucencies, thrombocytopenic purpura, anemia.

Late sequelae include motor and mental retardation.

Ref: Kliegman, Behrman, Jenson, Stanton, (2007), Chapter 244, “Rubella”, In the book, “Nelson’s Textbook of Pediatrics”, Volume 1, 18th Edition, New Delhi, Page 1340


Q. 3

Which of the following is an absolute contraindication for exercise testing?

 A

Unstable angina

 B

Aortic stenosis

 C

Peripheral vascular disease

 D

One week following myocardial infarction

Q. 3

Which of the following is an absolute contraindication for exercise testing?

 A

Unstable angina

 B

Aortic stenosis

 C

Peripheral vascular disease

 D

One week following myocardial infarction

Ans. B

Explanation:

Contraindication for stress test are:
  • Sever aortic stenosis
  • Acute myocarditis/pericarditis
  • Sever left main stem disease
  • Dissecting aneurysm
  • Ongoing tachy/brady arrhythmias
  • Sever hypertension (UNTREATED)
  • Congestive cardiac failure (UNTREATED)
Ref: Harrisons Internal Medicine, 18th Edition, Chapter 243

 


Q. 4

The pressure-volume curve is shifted to the left in which of the following valvular condition?

 A

Mitral regurgitation

 B

Aortic regurgitation

 C

Mitral stenosis

 D

Aortic stenosis

Q. 4

The pressure-volume curve is shifted to the left in which of the following valvular condition?

 A

Mitral regurgitation

 B

Aortic regurgitation

 C

Mitral stenosis

 D

Aortic stenosis

Ans. D

Explanation:

n aortic stenosis, HTN and HOCM there is pressure overload causing concentric left ventricular hypertrophy and shifts the diastolic pressure volume curve to left along its volume axis, so that at any diastolic volume ventricular diastolic pressure is abnormally elevated, although chamber stiffness may or may not be altered.

 
Diastolic function of the left ventricle is assessed using a LV end diastolic pressure volume curve. A shift of the curve upward and to the left indicates diastolic dysfunction. 
 
In aortic /mitral regurgitation where there is volume overload the entire diastolic pressure volume curve shifts to right indicating increased chamber stiffness.
 
Ref: Practical Cardiovascular Pathology, 2nd edition  By Mary Sheppard page 143. Diastology: Clinical Approach to Diastolic Heart Failure  By Allan L. Klein, Mario J. Garcia

Q. 5

The pressure-volume curve is shifted to the left in

 A

Mitral regurgitation

 B

Aortic regurgitation

 C

Mitral stenosis

 D

Aortic stenosis

Q. 5

The pressure-volume curve is shifted to the left in

 A

Mitral regurgitation

 B

Aortic regurgitation

 C

Mitral stenosis

 D

Aortic stenosis

Ans. D

Explanation:

D i.e. Aortic stenosis


Q. 6

In heart patient the worst prognosis during pregnancy is seen in :

 A

Mitral regurgitation

 B

Mitral valve prolapse

 C

Aortic stenosis

 D

Pulmonary stenosis

Q. 6

In heart patient the worst prognosis during pregnancy is seen in :

 A

Mitral regurgitation

 B

Mitral valve prolapse

 C

Aortic stenosis

 D

Pulmonary stenosis

Ans. C

Explanation:

Ans. is c i.e. Aortic stenosis

Remember a TUNDA : In general, regurgitant lesion do well in pregnancy unlike stenotic lesion, which worsen.

Let’s consider each of the options one by one and see what Williams has to say about each of them.

Option a” Mitral regurgitation

“M. R. is well tolerated during pregnancy probably due to decreased systemic vascular resistance which actually results in less regurgitation. Heart failure only rarely develops during pregnany.”

Option “b”        Mitral valve prolapse

“Pregnant women with mitral valve prolapse rarely have cardiac complications. In fact pregnancy induced hypervolemia may improve alignment of mitral valve.”

Option “c”         Aortic stenosis

“Although mild to moderate degree of aortic stenosis is well tolerated but severe degree is life threatening.”

Option d”         Pulmonary stenosis

“It is well tolerated during pregnancy and rarely causes any complication.”

Also know:           Major Cardiac Valve Disorders


Q. 7

True about is / are :

 A

MS surgery better avoided in pregnancy

 B

MR with PHT-definite indication for termination of pregnancy

 C

Aortic stenosis in young age is due to Bicuspid valve

 D

All

Q. 7

True about is / are :

 A

MS surgery better avoided in pregnancy

 B

MR with PHT-definite indication for termination of pregnancy

 C

Aortic stenosis in young age is due to Bicuspid valve

 D

All

Ans. D

Explanation:

Ans. a, b and c i.e. MS surgery better avoided in pregnancy; MR with PHT- definite indication for termination of pregnancy; and Aortic stenosis in young age is due to Bicuspid valve


Q. 8

Calcification of the aortic valve is seen in –

 A

Aortic stenosis

 B

Aortic regurgitation

 C

Marfan’s syndrome

 D

Hurler’s syndrome

Q. 8

Calcification of the aortic valve is seen in –

 A

Aortic stenosis

 B

Aortic regurgitation

 C

Marfan’s syndrome

 D

Hurler’s syndrome

Ans. A

Explanation:

Ans. is ‘a’ i.e., Aortic Stenosits

The most frequent calcific valvular diseases are ‑

  1. Calcific aortic stenosis
  2. Calcification of a congenitally bicuspid aortic valve.
  3. Mitral annular calcification

Q. 9

Severity of Aortic stenosis is determined by ?

 A

Late ejection systolic murmur

 B

ST -T changes

 C

LV Hypertrophy with displaced apex

 D

a and b

Q. 9

Severity of Aortic stenosis is determined by ?

 A

Late ejection systolic murmur

 B

ST -T changes

 C

LV Hypertrophy with displaced apex

 D

a and b

Ans. D

Explanation:

Ans. is ‘a’ i.e., Late ejection systolic murmur & ‘b’ i.e., ST-T changes


Q. 10

Pure left sided failure may be seen with ‑

 A

ASD

 B

Aortic stenosis

 C

Patent ductus arteriosus

 D

b and c

Q. 10

Pure left sided failure may be seen with ‑

 A

ASD

 B

Aortic stenosis

 C

Patent ductus arteriosus

 D

b and c

Ans. D

Explanation:

Ans. is ‘b’ i.e., Aortic stenosis; ‘c’ i.e., Petent ductus artriosus

o ASD usually does not cause HF.

o AS & PDA increase the strain on left ventricle           -3 LVF o PS increases the strain on right ventricular failure -4 RVF


Q. 11

William’s syndrome is associated with

 A

Congenital Supravalvular Aortic stenosis

 B

Congenital Subvalvular Aortic stenosis

 C

VSD

 D

ASD

Q. 11

William’s syndrome is associated with

 A

Congenital Supravalvular Aortic stenosis

 B

Congenital Subvalvular Aortic stenosis

 C

VSD

 D

ASD

Ans. A

Explanation:

A i.e. Congenital Supravalvular Aortic stenosis

William’s Syndrome or Idiopathic Hypercalcemia of Infancy

It is characterized by:

  1. Hypercalcemia d/ t abnormal sensitivity to vitamin D
  2. Supravalvular aortic stenosisQ & other congenital defects
  3. Mental retardation
  4. Elfin facies (Round face with full cheeks & lips)

Q. 12

Angina pectoris and Syncope are most likely to be associated with:

 A

Mitral stenosis

 B

Aortic stenosis

 C

Mitral regurgitation

 D

Tricuspid stenosis

Q. 12

Angina pectoris and Syncope are most likely to be associated with:

 A

Mitral stenosis

 B

Aortic stenosis

 C

Mitral regurgitation

 D

Tricuspid stenosis

Ans. B

Explanation:

Answer is B (Aortic stenosis)

Angina pectoris and Syncope are characteristic features of Aortic stenosis.

Aortic stenosis is characterized by the following cardinal features:

Dyspnea

Angina pectoris

Exertional syncope e

Sudden Death


Q. 13

A 63 year old man present with a triad of angina, syncope and congestive heart failure. Which of the following valvular heart lesion can be suspected :

 A

Mitral stenosis

 B

Tricuspid regurgitation

 C

Aortic stenosis

 D

Aortic regurgitation

Q. 13

A 63 year old man present with a triad of angina, syncope and congestive heart failure. Which of the following valvular heart lesion can be suspected :

 A

Mitral stenosis

 B

Tricuspid regurgitation

 C

Aortic stenosis

 D

Aortic regurgitation

Ans. C

Explanation:

Answer is C (Aortic stenosis)

`Angina pectoris, Exertional syncope, and dyspnea (LV failure) represent the charactristic clinical triad of Aortic stenosis.’

`Patients present with LV failure, angina pectoris or syncope all occurring with exertion.’

Symptoms of Aortic Stenosis

 

 

 

DyspneaQ                                                        Angina Pectoris’)

Syncope (Exertional)Q

• Results primarily from elevation of                 • Resultsfrom imbalance between

Syncope occurs due to stimulation of

pulmonary capillary pressure secondary        – increased myocardial oxygen

reflex baroceptors.

to LV failure                                                    requirement from increased myocardial

With exertion, the LV pressure rise

LVF and RVF may occur independently    mass and intraventricular pressure (and)

stimulating these baroceptors to

or together as ‘congestive cardiac              – reduced oxygen availability

peripherally vasodilate.

failure’. Aortic stenosis leads to

This results in an attempt to further

chronic excessive after load and results

increase cardiac output. Syncope occurs

in LVF followed by RVF, thus

when the stenotic valve does not allow an

presenting as CCF

adequate increase in cardiac output and

systemic BF’ falls.

Sudden Cardiac Death is the fourth cardinal feature of Valvular Aortic Stenosis

 

Aortic Stenosis is the most common valvular disease associated with sudden death.

 


Q. 14

Which of the following valvular heart diseases is most commonly associated with sudden death:

 A

Aortic Stenosis

 B

Mitral Stenosis

 C

Mitral Regurgitation

 D

Aortic Regurgitation

Q. 14

Which of the following valvular heart diseases is most commonly associated with sudden death:

 A

Aortic Stenosis

 B

Mitral Stenosis

 C

Mitral Regurgitation

 D

Aortic Regurgitation

Ans. A

Explanation:

Answer is A (Aortic Stenosis)

Aortic Stenosis is the most common valvular disease associated with sudden death.

The most common valve disease causing sudden death is aortic stenosis. In children subvalvular and supravalvular aortic stenosis may cause sudden death whereas in adults both congenitally bicuspid and trileaflet valves are the cause. Aortic stenosis accounts for approximately 2 percent of sudden death in adults’

The classic symptoms of the valvular type of aortic stenosis (regardless of type) include external dyspnoea, syncope, angina, and sudden cardiac death. The onset of symptoms is an ominous sign. The presence of angina does not necessarily indicate coexisting coronary disease; rather, it is related to increased left ventricular filling pressure causing subendocardial ischemia.


Q. 15

In severe aortic stenosis true finding is :

 A

Late systolic ejection click.

 B

Heaving with outward apex

 C

ST segment changes in ECG

 D

Loud S2

Q. 15

In severe aortic stenosis true finding is :

 A

Late systolic ejection click.

 B

Heaving with outward apex

 C

ST segment changes in ECG

 D

Loud S2

Ans. C

Explanation:

Answer is C (ST segment changes in ECG)

`ST and T wave changes on ECG favour severe aortic stenosis’ — Ghai Thus ST segment changes in ECG is the answer of choice.

  • Ejection click is not used to assess the severity of stenosis. The later having the peak of ejection systolic murmur, the more severe is the stenosis.
  • Cardiac size usually remains normal and so the apex though is not shifted outwards usually.
  • S2 does not show much variation in intensity. With increasing severity the S2 follows the following order normal split —> single —> paradoxical split

The clinical assessment of severity of aortic stenosis depends on the following: Ghai 6th/ 418

  • Presence of Symptoms : Symptomatic patients have severe Aortic stenosis however if the patient is asymptomatic it does not rule out severe Aortic stenosis.
  • Pulse pressure : Narrower the pulse pressure, the more sever the stenosis
  • Systolic thrill

Only in the suprasternal               Systolic thrill at the            Disappearance of an earlier

notch not at the second Rt.          second Rt. interspace         existent thrill interspace

Mild or critical aortic stenosis       Severe aortic stenosis         Very severe aortic stenosis

  • Peak of the ejection systolic murm ur :The later the peak of the ejection systolic murmur, the more severe is the stenosis
  • S,Split

Normal split

Closely split/ Normal/ Single

Paradoxical split

Mild

Moderate

Severe

  • Presence of S4
  • Presence of S3 indicates severe aortic stenosis with congestive cardiac failure.
  • ECG changes : ST & T wave changes in ECG
  • X Ray chest: Cardiac enlargement
  • Doppler echo: Quantitative gradient

Q. 16

Which of the following physical signs is seen in a patient with severe aortic stenosis:

 A

Opening snap

 B

Diastolic rumble

 C

Holosystolic murmur

 D

Delayed peak of systolic murmur

Q. 16

Which of the following physical signs is seen in a patient with severe aortic stenosis:

 A

Opening snap

 B

Diastolic rumble

 C

Holosystolic murmur

 D

Delayed peak of systolic murmur

Ans. D

Explanation:

Answer is D (Delayed peak of systolic murmur)

The ejection systolic murmur starts after the ejection click reaches a peak in midsystole.

With increasing severity of aortic stenosis the peak gets delayed so that the maximum intensity of the murmur is closer to the end rather than being midsystolic.


Q. 17

Exercise testing is absolutely contraindicated in which one of the following:

 A

One week following myocardial infarction

 B

Unstable angina

 C

Aortic stenosis

 D

Peripheral vascular disease

Q. 17

Exercise testing is absolutely contraindicated in which one of the following:

 A

One week following myocardial infarction

 B

Unstable angina

 C

Aortic stenosis

 D

Peripheral vascular disease

Ans. C

Explanation:

Answer is C (Aortic stenosis)

“Many of the traditional contraindications such as recent myocardial infarction or congestive heart failure are no longer considered if the patient is stable and ambulatory but Aortic Stenosis remains a contraindication”

Contraindications to exercise stress testing: 

  1. Acute myocardial infarction (< 4 - 5 days)
  2. Rest angina < 48 hours
  3. Unstable rhythm
  4. Severe Aortic Stenosis
  5. Acute Myocarditis
  6. Uncontrolled heart failure
  7. Active infective endocarditis

Exercise testing should also not be done during an episode of unstable angina and its presence in the options confuses the issue. However, going with what CMDT has to say, aortic stenosis remains the answer of choice. Exercise testing in unstable angina : Unstable angina is a term used to describe patients who present with rapidly worsening angina, severe angina at rest or prolonged or ischaemia chest pain without ECG or enzyme evidence of MI.

Unstable angina episode             Admit, Bed Rest, Aspirin, p blockers              Exercise Tolerance test

Exercise testing is indicated in unstable angina once the plaque has stabilized and is arranged later, in order to assess the patients need for coronary angiography if the test is positive at low work load.


Q. 18

Calcification of the aortic valve is seen in :

 A

Aortic stenosis

 B

Aortic regurgitation

 C

Marfan’s syndrome

 D

Hurler’s syndrome

Q. 18

Calcification of the aortic valve is seen in :

 A

Aortic stenosis

 B

Aortic regurgitation

 C

Marfan’s syndrome

 D

Hurler’s syndrome

Ans. A

Explanation:

Answer is A (Aortic Stenosis)

Aortic calcification is most commonly associated with Aortic stenosis

Aortic Calcification in Aortic stenosis is usually apparent on fluoroscopic examination with an image intensifier or by echocardiography.

The absence of aortic calcification in an adult suggests that severe valvular Aortic stenosis is not present.


Q. 19

A 50-year-old asymptomatic man with established aortic stenosis undergoes Exercise Stress testing according to Bruce Protocol. The stress test was terminated at 11 minutes due to development of fatigue and dyspnea. Regional pressure gradient was observed to be 60 mm Hg between the two sides of the aortic valve. What is the best management.

 A

Angiogram

 B

Aortic valve replacement

 C

Aortic Balooning

 D

All

Q. 19

A 50-year-old asymptomatic man with established aortic stenosis undergoes Exercise Stress testing according to Bruce Protocol. The stress test was terminated at 11 minutes due to development of fatigue and dyspnea. Regional pressure gradient was observed to be 60 mm Hg between the two sides of the aortic valve. What is the best management.

 A

Angiogram

 B

Aortic valve replacement

 C

Aortic Balooning

 D

All

Ans. B

Explanation:

Answer is B (Aortic valve replacement )

The patient in question has asymptomatic aortic stenosis but develops symptoms on exercise (abnormal/positive exercise test). Also the presence of mean pressure gradient of 60mm Hg put this patient into the category of ‘Very Severe Aortic Stenosis’ or ‘Critical Aortic Stenosis’.

Optimal management of asymptomatic severe Aortic Stenosis continues to be a source of ongoing clinical controversy. Surgical Aortic Valve Replacement and Watchfull waiting with frequent reassessments (observation), both continue to be legitimate though debatable treatment options.

Since the patient in question has ‘Very Severe AS’ and ‘Abnormal Stress Testing’ he should be considered for surgical intervention in the form of Aortic Valve Replacement (A VR).

50-year-old patient with Asymptomatic Severe Aortic Stenosis

=5m/s, mean gradient >=50mm Hg, aortic valve ara <=0.6 cm2) when operative mortality is < 1% " align="left" height="132" width="316">Positive Exercise Stress Test

 

Mean Pressure Gradient > 60 mm Hg

Symptoms during exercise such as dyspnea, angina, and syncope or near syncope constitute positive criteria indicating an abnormal stress test in patients with asymptomatic aortic stenosis.

 

Mean pressure gradient > 60 mm Hg and/or Aortic valve area < 0.6 cm` and /or Aortic Jet velocity > 5.0 m per second is classified as ‘Extremely Severe Aortic Stenosis’ (Critical Aortic Stenosis)

‘Severe Aortic Stenosis with an abnormal response to exercise is considered a Class Hb indication for Aortic Valve Replacement according to the ACC/AHA Guidelines.’

‘Severe Aortic Stenosis with an abnormal response to exercise is considered a Class IC indication for Aortic Valve Replacement according to European Cardiology Society Guidelines (ECS Guidelines)’

 

 

‘Extremely Severe Aortic Stenosis (mean gradient > 60 mm Hg) is considered a class Ilb indication for Aortic Valve Replacement according to the ACC/AHA Guidelines.’

 

Study

Conclusion

I. ‘Clinical outcomes in non-surgically

‘Surgery should always be considered in very severe AS

managed patients with very severe versus severe

regardless of symptoms, and particular attention needs to

aortic stenosis’

be paid to their extremely poor outcomes.’

(Heart doi:O. 1136/heartjn1-2011-300137; Valvular

heart disease; Original article)

 

2. ‘Early Surgery Versus Conventional

‘Compared with the conventional treatment strategy,

Treatment in Asymptomatic Very Severe Aortic

early surgery is associated with improved survival by

Stenosis’

effectively decreasing cardiac mortality and sudden

(Tirculation’: 2010; 121: 1502-1509; Valvular heart

cardiac death in patients with very severe AS. This result

disease; Original article)

suggests that early surgery can be a therapeutic option to

further improve clinical outcome in asymptomatic patients

with very severe AS and low operative risk.’

 

Classification of Aortic Valve Stenosis Severity

 

Severity

Valve Area (cm2)

Maximum Aortic Velocity

(m/sec))

Mean Pressure Gradient

(mm Hg)

Mild

1.5 – 2.0

2.5 – 3.0

<25

Moderate

1.0 –1.5

3.0-4.0

25-40

Severe

0.6-1.0

>4.0

>40

Critical (Extremely Severe)

<0.6

>5.0

>50-60


Q. 20

Sub-valvular Aortic Stenosis is known to be associated with all of the following, except:

 A

Aortic Regurgitation

 B

Coarctation of Aorta

 C

Tricuspid Valve Atresia

 D

Ventricular Septal Defect

Q. 20

Sub-valvular Aortic Stenosis is known to be associated with all of the following, except:

 A

Aortic Regurgitation

 B

Coarctation of Aorta

 C

Tricuspid Valve Atresia

 D

Ventricular Septal Defect

Ans. C

Explanation:

Answer is C (Tricuspid valve atresia)

Tricuspid Valve Atresia is not associated with Subvalvular Aortic Stenosis. Subvalvular Aortic Stenosis (Subaortic Stenosis)

  • Subaortic stenosis is defined as obstruction to left ventricular outflow below the aortic valve.
  • It is the second most common form of fixed aortic stenosis.
  • The most common form of subaortic stenosis is ‘Discrete’

Subaortic Stenosis is further classified into ‘Discrete’ type and ‘Diffuse Tunnel-Type’ narrowing

Types of Subaortic Stenosis

`Discrete’ (85 to 90 percent) : Most common form of subaortic stenosis `Diffuse’ or ‘Long Segment Tunnel-Type'(10%to 15% )

Some have attempted to subdivide the discrete form into membranous and fibromuscular but such distinction is difficult

  • Boys are more frequently affected than girls at a ratio of approximately 2:1.
  • Subaortic stenosis is associated with other cardiac abnormalities in 50% to 70% of patients

The two most_ frequently associated defects with subaortic stenosis are Ventricular Septal Defect and Coarctation of Aorta.

Aortic regurgitation is the most common complication of subaortic stenosis occurring in as many as 50 percent of patients

Cardiac Anomalies Associated with subaortic stenosis

  • Aortic regurgitation
  • Aortic valve stenosis
  • Patent ductus arteriosus
  • Coarctation of the aorta
  • Interrupted aortic arch
  • Mitral valve abnormalities
  • Ventricular septal defect
  • Repaired a trioventricular septal defects
  • Double-chambered right ventricle

Q. 21

The most common complication of Sub-valvular Aortic Stenosis is:

 A

Aortic Regurgitation

 B

Mitral Regurgitation

 C

Tricuspid regurgitation

 D

Pulmonary Regurgitation

Q. 21

The most common complication of Sub-valvular Aortic Stenosis is:

 A

Aortic Regurgitation

 B

Mitral Regurgitation

 C

Tricuspid regurgitation

 D

Pulmonary Regurgitation

Ans. A

Explanation:

Answer is A (Aortic Regurgitation)

Aortic regurgitation is the most common complication of subaortic stenosis.

Aortic regurgitation is the most common complication of subaortic stenosis occurring in more than 50% of patients. Aortic Regurgitation is believed to be caused from Valvular damage due to the high-pressure Subvalvular systolic jet originating at the level of stenosis.


Q. 22

Aggravation of symptoms of angina in a patient when given nitrates is seen in :

 A

Aortic regurgitation

 B

Mitral regurgitation

 C

Single left coronary artery stenosis

 D

Idiopathic hypertrophic subaortic stenosis

Q. 22

Aggravation of symptoms of angina in a patient when given nitrates is seen in :

 A

Aortic regurgitation

 B

Mitral regurgitation

 C

Single left coronary artery stenosis

 D

Idiopathic hypertrophic subaortic stenosis

Ans. D

Explanation:

Answer is D (Idiopathic Hypertrophic Sub Aortic Stenosis):

Idiopathic hypertrophic subaortic stenosis (HOCM) is a dynamic outflow obstruction which is increased by any mechanism decreasing the preload. Nitrates decrease the preload, & the volume of blood in LV & thereby increase the dynamic obstruction & symptoms of angina.


Q. 23

Pressure difference of 5mm Hg between the two upper limbs occurs in which congenital heart disease:

 A

TOF

 B

TGA

 C

HOCM

 D

Supra –valvular aortic stenosis

Q. 23

Pressure difference of 5mm Hg between the two upper limbs occurs in which congenital heart disease:

 A

TOF

 B

TGA

 C

HOCM

 D

Supra –valvular aortic stenosis

Ans. D

Explanation:

Answer is D (Supravalvular Aortic stenosis)

In supravalvular aortic stenosis the direction of jet of flow tends to be directly directed into the innominate artery. This often results in the direct impact pressure of the central jet being transmitted to right anti, thus making the rit,ht anti pressure hit,ther than the left


Q. 24

Most common cause of death in aortic stenosis patients is:        

March 2005

 A

Pulmonary edema

 B

Atrial flutter

 C

IHD with ventricular fibrillation

 D

Cerebral embolism

Q. 24

Most common cause of death in aortic stenosis patients is:        

March 2005

 A

Pulmonary edema

 B

Atrial flutter

 C

IHD with ventricular fibrillation

 D

Cerebral embolism

Ans. C

Explanation:

Ans. C: IHD with ventricular fibrillation

Aortic stenosis can be a serious and potentially life threatening condition. Some of the possible complications include:

  • Pulmonary oedema
  • Cardiomegaly
  • Congestive heart failure
  • Heart arrhythmia.

Some arrhythmias in the ventricles may be associated with cardiac death, such as ‘ventricular fibrillation’ .


Q. 25

Which of the following is not a common manifestation of the disorder shown in the picture below ? 

 A

Deafness.

 B

PDA.

 C

Aortic stenosis.

 D

Mental retardation.

Q. 25

Which of the following is not a common manifestation of the disorder shown in the picture below ? 

 A

Deafness.

 B

PDA.

 C

Aortic stenosis.

 D

Mental retardation.

Ans. C

Explanation:

The disorder shown in the picture above represents congenital Rubella.

Congenital rubella syndrome (CRS) results in a range of transient abnormalities at birth, which need not concern us now, congenital defects including sensorineural deafness, congenital heart disease, cataract, choroidoretinitis, growth retardation, microcephaly, mental retardation and urogenital abnormalities. The classic diagnostic triad was cataracts, cardiac abnormalities and deafness. Delayed consequences include diabetes, thyroid disorders, behavioural disorders and panencephalitis. About 40% of children weighed less than 2.5 kg at birth, and most failed to catch up with their peers subsequently.

Nerve deafness is the single most common clinical finding among infant with congenital Rubella syndrome.

PDA is the most common CHD in congenital rubella syndrome.

Classical triad of congenital rubella consists of –3 Cataract, Deafness, CHD

o Mental retardation is also common.


Q. 26

A patient has dyspnea, syncope and angina. What is the most likely diagnosis?

 A

Aortic stenosis

 B

Aortic regurgitation

 C

Atrial septal defect

 D

Ventricular septal defect

Q. 26

A patient has dyspnea, syncope and angina. What is the most likely diagnosis?

 A

Aortic stenosis

 B

Aortic regurgitation

 C

Atrial septal defect

 D

Ventricular septal defect

Ans. A

Explanation:

Ans. a. Aortic stenosis

Patients of aortic stenosis have dyspnea, syncope and angina.

‘Most patients with pure or predominant AS have gradually increasing obstruction over years, but do not become symptomatic until the sixth to eighth decades. Exertional dyspnea, angina pectoris, and syncope are the three cardinal symptoms. Often, there is a history of insidious progression of fatigue and dyspnea associated with gradual curtailment of activities. Dyspnea results primarily from elevation of the pulmonary capillary pressure caused by elevations of LVdiastolic pressures secondary to reduced left ventricular compliance and impaired relaxation. Angina pectoris usually develops somewhat later and reflects an imbalance between the augmented myocardial oxygen requirements and reduced oxygen availability. Exertional syncope may result from a decline in arterial pressure caused by vasodilation in the exercising muscles and inadequate vasoconstriction in non-exercising muscles in the face of a fixed CO, or from a sudden fall in CO produced by an arrhythmia. ‘- Harrison 18/e p1939

Aortic stenosis

Etiology:

  • Congenital (bicuspid, unicuspid), Degenerative calcific, Rheumatic fever, Radiation
  • Symptoms:
  • AS is rarely of clinical importance until the valve orifice has narrowed to approximately 1 cm2.
  • Once symptoms occur, valve replacement is indicatedQ.
  • Most patients with pure or predominant AS have gradually increasingQbstruction over years, but do not become symptomatic until the sixth to eighth decadesQ
  • Exertional dyspnea, angina pectoris, and syncope are the three cardinal symptomsQ
  • Often, there is a history of insidious progression of fatigue and dyspnea associated with gradual curtailment of activitiesQ
  • Because the CO at rest is usually well maintained until late in the course, marked fatigability, weakness, peripheral cyanosis, cachexia, and other clinical manifestations of a low CO are usually not prominent until this stage is reachedQ
  • Orthopnea, paroxysmal nocturnal dyspnea, and pulmonary edema, i.e., symptoms of LV failure, also occur only in the advanced stages of the diseaseQ
  • Severe pulmonary hypertension leading to RV failure and systemic venous hypertension, hepatomegaly, AF, and TR are usually late findings in patients with isolated severe ASQ
  • Death in patients with severe AS occurs most commonly in the 7th and 8th decadesQ

Auscultation:

  • An early systolic ejection sound is frequently audible in children, adolescents, and young adults with congenital BAV diseaseQ.
  • Paradoxical splitting of S2Q
  • S4: Audible at the apexQ
  • S3 generally occurs late in the courseQ
  • Ejection (mid) systolic murmurQ

Ejection (mid) systolic murmur in AS

  • Commences shortly after the SiQ
  • Increases in intensity to reach a peak toward the middle of ejectionQ
  • Ends just before aortic valve closureQ
  • Characteristically low-pitched, rough and rasping in character, and loudest at the base of the heart, most commonly in the 2″ right intercostal spaceQ.
  • Transmitted upward along the carotid arteriesQ
  • Occasionally, transmitted downward and to the apex, where it may be confused with the systolic murmur of MR (Gallavardin effectQ).

Echocardiography:

  • The key findings on TTE are thickening, calcification, and reduced systolic opening of the valve leaflets and LV hypertrophyQ.
  • Eccentric closure of the aortic valve cusps is characteristic of congenitally bicuspid valvesQ
Severity of AS Valve Area
Mild 1.5-2 cm2
Moderate 1-1.5 cm2
 Severe <1 cm2
  • Echocardiography is useful for identifying coexisting valvular abnormalities; for differentiating valvular AS from other forms of LV outflow obstruction: and for measurement of the aortic root and proximal ascending aortic dimensionQ.
  • Dobutamine stress echocardiography is useful for the evaluation of patients with AS and severe LV systolic dysfunction (EF < 0.35), in whom the severity of the AS can often be difficult to judge.Q

Q. 27

Vasopressor of choice in anesthesia for a patient of aortic stenosis, who develops hypotension during surgery:

 A

Ephedrine

 B

Dopamine

 C

Dobutamine

 D

Phenylephrine

Q. 27

Vasopressor of choice in anesthesia for a patient of aortic stenosis, who develops hypotension during surgery:

 A

Ephedrine

 B

Dopamine

 C

Dobutamine

 D

Phenylephrine

Ans. D

Explanation:

Ans. d. Phenylephrine

Thenylephrine is the vasopressor of choice to restore coronary perfusion in patients with severe aortic stenosis when under general anesthesia.’

Phenylephrine is the vasopressor of choice for correcting hypotension in parturients with aortic stenosis.’ Phenylephrine is preferred over ephedrine as a vasopressor because the former lacks beta adrenergic agonist activity.’

Phenylephrine

  • Phenylephrine is the vasopressor of choice to restore coronary perfusion in patients with severe aortic stenosis when under general anesthesia.
  • Phenylephrine is the vasopressor of choice for correcting hypotension in parturients with aortic stenosis.

Q. 28

A 71 year old patient presented with chest pain and syncope.X ray shows the following features.What can be the most possible diagnosis?

 

 A

Mitral Stenosis

 B

Pulmonary Stenosis

 C

Aortic Stenosis

 D

Double Aortic Arch

Q. 28

A 71 year old patient presented with chest pain and syncope.X ray shows the following features.What can be the most possible diagnosis?

 

 A

Mitral Stenosis

 B

Pulmonary Stenosis

 C

Aortic Stenosis

 D

Double Aortic Arch

Ans. C

Explanation:

Ans:C.)Aortic Stenosis.

Image shows:

Frontal chest radiograph in aortic stenosis shows a dilated ascending aorta (white arrow) that abnormally projects farther to the right than the right heart border. This is caused by
post-stenotic dilatation of the aorta.

AORTIC STENOSIS

General Considerations 

  • Most often as result of degeneration of bicuspid aortic valve
  • Less commonly rheumatic heart disease or secondary to degeneration 
    of a tricuspid aortic valve in person > 65 

Location

  • Supravalvular
    • Uncommon
    • Associated with William’s Syndrome
      • Hypercalcemia
      • Elfin facies
      • Pulmonary stenoses
      • Hypoplasia of aorta
      • Stenoses in
        • Renal, celiac, superior mesenteric arteries
  • Valvular
    • Most common
    • Either congenital (from a bicuspid aortic valve) or acquired
      • Bicuspid aortic valve is the most common congenital cardiac anomaly
        • 0.5 –2%
  • Subvalvular
    • Associated with
      • Hypoplastic left heart syndrome
      • Idiopathic Hypertrophic Subaortic Stenosis
      • Hypertrophic cardiomyopathy
      • Subaortic fibrous membrane 

Types

  • Congenital aortic stenosis (more common)
    • Most frequent congenital heart disease associated with 
      intra-uterine growth retardation (IUGR)
      • Subvalvular (30%)
      • Valvular (70%)
        • Degeneration of bicuspid valve
      • Supravalvular
  • Acquired aortic stenosis
    • Rheumatic valvulitis
      • Almost invariably associated with mitral valve disease
    • Fibrocalcific senile aortic stenosis
      • Degenerative 

Clinical Findings

  • Asymptomatic for many years
  • Classical triad
    • Angina
    • Syncope
    • Shortness of breath (heart failure)
  • Systolic ejection murmur
  • Carotid pulsus parvus et tardus
  • Diminished aortic component of 2nd heart sound
  • Sudden death in severe stenosis after exercise
    • Diminished flow in coronary arteries causes ventricular dysrhythmias
      and fibrillation
    • Decompensation leads to left ventricular dilatation and pulmonary 
      venous congestion

Imaging Findings 

  • In older children or young adults
    • Prominent ascending aorta
      • Poststenotic dilatation of ascending aorta
        • Due to turbulent flow
    • Left ventricular heart configuration
      • Normal-sized or enlarged left ventricle
      • Concentric hypertrophy of left ventricle produces a relatively small
        left ventricular chamber with thick walls
    • Heart size is frequently normal
  • In adults >30 years
    • Prominent ascending aorta
      • Poststenotic dilatation of ascending aorta
        • Due to turbulent flow
    • Calcification of aortic valve (best seen on RAO)
    • Normal to enlarged left ventricle


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