Aortic stenosis - Revision history

Chris.Rishel at 10:55, 28 June 2021

2021-06-28T10:55:43Z

← Older revision		Revision as of 03:55, 28 June 2021
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	==Epidemiology<!-- Describe the epidemiology of this comorbidity -->==		==Epidemiology<!-- Describe the epidemiology of this comorbidity -->==
			Test
	[[Category:Comorbidity]]		[[Category:Comorbidity]]
	[[Category:Cardiovascular disorders]]		[[Category:Cardiovascular disorders]]

Chris.Rishel at 05:50, 2 February 2021

2021-02-02T05:50:57Z

← Older revision		Revision as of 22:50, 1 February 2021
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	{{Infobox comorbidity		{{Infobox comorbidity
	\| other_names =		\| other_names =
	\| image = Severe_aortic_valve_stenosis_E00264_(CardioNetworks_ECHOpedia).jp		\| image = Severe_aortic_valve_stenosis_E00264_(CardioNetworks_ECHOpedia).jpg
	\| caption = An echocardiogram showing a valve pressure gradient consistent with severe aortic stenosis		\| caption = An echocardiogram showing a valve pressure gradient consistent with severe aortic stenosis
	\| anesthetic_relevance = <span class="text-critical">Critical</span>		\| anesthetic_relevance = <span class="text-critical">Critical</span>

Chris.Rishel at 05:50, 2 February 2021

2021-02-02T05:50:46Z

@@ Line 1: / Line 1: @@
-{{Infobox comorbidity|other_names=|image=Severe_aortic_valve_stenosis_E00264_(CardioNetworks_ECHOpedia).jpg|caption=An echocardiogram showing a valve pressure gradient consistent with severe aortic stenosis|anesthetic_relevance=<span class="text-critical">Critical</span>|specialty=Cardiology|signs_symptoms=Angina, dyspnea, peripheral edema, syncope|diagnosis=[[Echocardiogram]]|treatment=Valve replacement surgery}}
+{{Infobox comorbidity
 '''Aortic stenosis''' is the narrowing of the outflow tract of the left ventricle due to calcification of the aortic valve.
 == Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. --> ==

Chris.Rishel at 19:46, 29 January 2021

2021-01-29T19:46:42Z

← Older revision		Revision as of 12:46, 29 January 2021
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	==Diagnosis<!-- Describe how this comorbidity is diagnosed. -->==		==Diagnosis<!-- Describe how this comorbidity is diagnosed. -->==
	{\| class="wikitable" align="right"		{\| class="wikitable" align="right"
	! colspan="3" \|'''Severity of aortic stenosis'''~~<ref name="uas" />~~		! colspan="3" \|'''Severity of aortic stenosis'''
	\|-		\|-
	!Degree!! Mean gradient <br> (mmHg)!!Aortic valve area<br> (cm<sup>2</sup>)		!Degree!! Mean gradient <br> (mmHg)!!Aortic valve area<br> (cm<sup>2</sup>)

Chris.Rishel at 19:14, 29 January 2021

2021-01-29T19:14:58Z

← Older revision		Revision as of 12:14, 29 January 2021
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	[[Category:Valvular heart disease]]		[[Category:Valvular heart disease]]

			== References ==
	<references />		<references />

Chris.Rishel at 18:55, 29 January 2021

2021-01-29T18:55:51Z

← Older revision		Revision as of 11:55, 29 January 2021
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	=== Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. --> ===		=== Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. --> ===

	===== Monitoring =====		==== Monitoring ====

	* For severe disease, a pre-induction [[arterial line]] should be placed to rapidly detect hemodynamic changes.		* For severe disease, a pre-induction [[arterial line]] should be placed to rapidly detect hemodynamic changes.
	* Advanced monitoring such as a [[pulmonary artery catheter]] or [[transesophageal echocardiography]] can be considered.		* Advanced monitoring such as a [[pulmonary artery catheter]] or [[transesophageal echocardiography]] can be considered.

	===== Hemodynamics =====		==== Hemodynamics ====

	* '''Hypotension''' should be avoided to preserve afterload (i.e. coronary perfusion pressure). Treat with afterload-increasing agents such as [[phenylephrine]].		* '''Hypotension''' should be avoided to preserve afterload (i.e. coronary perfusion pressure). Treat with afterload-increasing agents such as [[phenylephrine]].
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	* '''Tachycardia''' and '''hypertension''' should be avoided to preserve left ventricular diastolic filling and reduce myocardial oxygen demand. Treat with increasing anesthetic depth or short-acting beta-blockade with [[esmolol]].		* '''Tachycardia''' and '''hypertension''' should be avoided to preserve left ventricular diastolic filling and reduce myocardial oxygen demand. Treat with increasing anesthetic depth or short-acting beta-blockade with [[esmolol]].

	===== Neuraxial anesthesia =====		==== Neuraxial anesthesia ====
	Neuraxial anesthesia is contraindicated in all but mild disease due to the risk of decreased [[systemic vascular resistance]] leading to decreased [[diastolic blood pressure]] and reduced myocardial perfusion		Neuraxial anesthesia is contraindicated in all but mild disease due to the risk of decreased [[systemic vascular resistance]] leading to decreased [[diastolic blood pressure]] and reduced myocardial perfusion

	=== Postoperative management<!-- Describe how this comorbidity may influence postoperative management. --> ===		=== Postoperative management<!-- Describe how this comorbidity may influence postoperative management. --> ===
			Patients with significant disease may require close postoperative monitoring to quickly identify and manage any hemodynamic instability.

	== Related surgical procedures<!-- List and briefly describe any procedures which may be performed specifically to treat this comorbidity or its sequelae. If none, this section may be removed. --> ==		==Related surgical procedures<!-- List and briefly describe any procedures which may be performed specifically to treat this comorbidity or its sequelae. If none, this section may be removed. -->==

	* [[Aortic valve repair or replacement]]		*[[Aortic valve repair or replacement]]
	* [[Transcatheter aortic valve replacement]]		*[[Transcatheter aortic valve replacement]]
			*[[Balloon valvuloplasty]]

	== Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. --> ==		==Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. -->==
	In aortic stenosis, the opening of the aortic valve is narrowed, typically due to calcification from tissue damage over time. The most common cause is valve degeneration in older patients, though stenosis may develop in younger patients with a [[bicuspid aortic valve]]. It is thought that stenosis results from inflammation due to endothelial cell damage from increased mechanical stress.		In aortic stenosis, the opening of the aortic valve is narrowed, typically due to calcification from tissue damage over time. The most common cause is valve degeneration in older patients, though stenosis may develop in younger patients with a [[bicuspid aortic valve]]. It is thought that stenosis results from inflammation due to endothelial cell damage from increased mechanical stress.

	As aortic stenosis progresses, higher pressures must be generated by the left ventricle to maintain cardiac output. This initially leads to the development of concentric [[left ventricular hypertrophy]]. In later stages of the disease, the left ventricle dilates and the ventricular walls thin, resulting in reduced systolic function.		As aortic stenosis progresses, higher pressures must be generated by the left ventricle to maintain cardiac output. This initially leads to the development of concentric [[left ventricular hypertrophy]]. In later stages of the disease, the left ventricle dilates and the ventricular walls thin, resulting in reduced systolic function.

	== Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> ==		==Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> ==

	===== Signs =====		===Signs===

	* Slow/late peripheral pulses (''pulsus parvus et tardus'')		* Slow/late peripheral pulses (''pulsus parvus et tardus'')
	* Harsh systolic crescendo-decrescendo murmur		*Harsh systolic crescendo-decrescendo murmur
	** Best auscultated at the right upper sternal border at the 2nd intercostal space		** Best auscultated at the right upper sternal border at the 2nd intercostal space
	** May radiate to both carotids		** May radiate to both carotids
	* Decreased intensity of the second heart sound (A<sub>2</sub>)		* Decreased intensity of the second heart sound (A<sub>2</sub>)

	===== Symptoms =====		=== Symptoms ===

	* Angina		* Angina
	* Decreased exercise tolerance		*Decreased exercise tolerance
	* Dyspnea		*Dyspnea
	* Syncope		*Syncope
	* Symptoms of [[congestive heart failure]]		*Symptoms of [[congestive heart failure]]

	== Diagnosis<!-- Describe how this comorbidity is diagnosed. --> ==		==Diagnosis<!-- Describe how this comorbidity is diagnosed. -->==
	{\|class="wikitable" align="right"		{\| class="wikitable" align="right"
	!colspan=3\|'''Severity of aortic stenosis'''~~</caption>~~<ref name="uas"/>		! colspan="3" \|'''Severity of aortic stenosis'''<ref name="uas" />
	\|-		\|-
	! Degree !! Mean gradient <br> (mmHg) !! Aortic valve area<br> (cm<sup>2</sup>)		!Degree!! Mean gradient <br> (mmHg)!!Aortic valve area<br> (cm<sup>2</sup>)
	\|-		\|-
	\| Mild \|\| <25 \|\| >1.5		\|Mild \|\| <25\|\|>1.5
	\|-		\|-
	\| Moderate \|\| 25 - 40 \|\| 1.0 - 1.5		\|Moderate\|\|25 - 40 \|\|1.0 - 1.5
	\|-		\|-
	\| Severe \|\| >40 \|\| < 1.0		\|Severe\|\|>40\|\|< 1.0
	\|-		\|-
	\| Very severe \|\| >70 \|\| < 0.6		\|Very severe\|\|>70\|\|< 0.6
	\|}Aortic stenosis may be initially suspected from the physical exam findings described above. Definitive diagnosis and classification of disease severity can be determined using [[Echocardiogram\|echocardiography]] or [[heart catheterization]].		\|}Aortic stenosis may be initially suspected from the physical exam findings described above. Definitive diagnosis and classification of disease severity can be determined using [[Echocardiogram\|echocardiography]] or [[heart catheterization]].

	== Treatment<!-- Summarize the treatment of this comorbidity. Add subsections as needed. --> ==		==Treatment<!-- Summarize the treatment of this comorbidity. Add subsections as needed. -->==

	=== Medication<!-- List medications used to manage this comorbidity. --> ===		===Medication<!-- List medications used to manage this comorbidity. -->===
			In general, medication has poor efficacy in the treatment of aortic stenosis. However, medical therapy is important to manage concomitant cardiac diseases such as [[heart failure]], [[hypertension]] and symptoms such as [[angina]].

	=== ~~Prognosis<!-- Describe the prognosis of this comorbidity -->~~ ===		=== Surgery ===
			Severe symptomatic aortic stenosis is typically treated with [[Aortic valve repair or replacement\|aortic valve replacement]]. For patients who are poor candidates for surgical valve replacement, [[transcatheter aortic valve replacement]] is an alternative. [[Balloon valvuloplasty]] is can be effective in infants and children, but has limited efficacy in adults since the valve generally returns to a stenosed state.

	== Epidemiology<!-- Describe the epidemiology of this comorbidity --> ==		=== Prognosis<!-- Describe the prognosis of this comorbidity -->===
			Untreated severe symptomatic aortic stenosis has a poor prognosis, with a 2-year survival rate of 50-60%. For patients who undergo valve replacement, life expectancy is about 5 years less than the general population for patients under 65, and similar to patients without aortic stenosis for patients over 65.

			==Epidemiology<!-- Describe the epidemiology of this comorbidity -->==

	[[Category:Comorbidity]]		[[Category:Comorbidity]]
	[[Category:Cardiovascular disorders]]		[[Category:Cardiovascular disorders]]
	[[Category:Valvular heart disease]]		[[Category:Valvular heart disease]]

			<references />

Chris.Rishel at 18:32, 29 January 2021

2021-01-29T18:32:06Z

← Older revision		Revision as of 11:32, 29 January 2021
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	== Diagnosis<!-- Describe how this comorbidity is diagnosed. --> ==		== Diagnosis<!-- Describe how this comorbidity is diagnosed. --> ==
	Aortic stenosis may be initially suspected from the physical exam findings described above. Definitive diagnosis and classification of disease severity can be determined using [[Echocardiogram\|echocardiography]] or [[heart catheterization]].
	{\|class="wikitable" align="right"		{\|class="wikitable" align="right"
	!colspan=3\|'''Severity of aortic stenosis'''</caption><ref name="uas"/>		!colspan=3\|'''Severity of aortic stenosis'''</caption><ref name="uas"/>
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	\|-		\|-
	\| Very severe \|\| >70 \|\| < 0.6		\| Very severe \|\| >70 \|\| < 0.6
	\|}		\|}Aortic stenosis may be initially suspected from the physical exam findings described above. Definitive diagnosis and classification of disease severity can be determined using [[Echocardiogram\|echocardiography]] or [[heart catheterization]].

	== Treatment<!-- Summarize the treatment of this comorbidity. Add subsections as needed. --> ==		== Treatment<!-- Summarize the treatment of this comorbidity. Add subsections as needed. --> ==

Chris.Rishel at 18:31, 29 January 2021

2021-01-29T18:31:33Z

← Older revision		Revision as of 11:31, 29 January 2021
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	== Diagnosis<!-- Describe how this comorbidity is diagnosed. --> ==		== Diagnosis<!-- Describe how this comorbidity is diagnosed. --> ==
	Aortic stenosis may be initially suspected from the physical exam findings described above. Definitive diagnosis and classification of disease severity can be determined using [[Echocardiogram\|echocardiography]] or [[heart catheterization]].		Aortic stenosis may be initially suspected from the physical exam findings described above. Definitive diagnosis and classification of disease severity can be determined using [[Echocardiogram\|echocardiography]] or [[heart catheterization]].
	{\|align="right"		{\|class="wikitable" align="right"
	!colspan=3\|'''Severity of aortic stenosis'''</caption><ref name="uas"/>		!colspan=3\|'''Severity of aortic stenosis'''</caption><ref name="uas"/>
	\|-		\|-

Chris.Rishel at 18:31, 29 January 2021

2021-01-29T18:31:08Z

@@ Line 1: / Line 1: @@
-{{Infobox comorbidity|other_names=|image=Severe_aortic_valve_stenosis_E00264_(CardioNetworks_ECHOpedia).jpg|caption=An echocardiogram showing a valve pressure gradient consistent with severe aortic stenosis|anesthetic_relevance=<span class="text-critical">Critical</span>|specialty=Cardiology|signs_symptoms=Decreased exercise tolerance, dyspnea, syncope, chest pain|diagnosis=[[Echocardiogram]]|treatment=Valve replacement surgery}}
+{{Infobox comorbidity|other_names=|image=Severe_aortic_valve_stenosis_E00264_(CardioNetworks_ECHOpedia).jpg|caption=An echocardiogram showing a valve pressure gradient consistent with severe aortic stenosis|anesthetic_relevance=<span class="text-critical">Critical</span>|specialty=Cardiology|signs_symptoms=Angina, dyspnea, peripheral edema, syncope|diagnosis=[[Echocardiogram]]|treatment=Valve replacement surgery}}
 '''Aortic stenosis''' is the narrowing of the outflow tract of the left ventricle due to calcification of the aortic valve.
 == Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. --> ==
 === Preoperative optimization<!-- Describe how this comorbidity may influence preoperative evaluation and optimization of patients. --> ===
-Asymptomatic aortic stenosis may be initially detected on physical exam. Peripheral pulses may be weak and late (sometimes called ''pulsus parvus et tardus''). A loud systolic crescendo-decrescendo murmur may also be present, which is best heard at the right upper sternal border at the 2nd intercostal space. This murmur may also radiate to the carotid arteries.
+Asymptomatic aortic stenosis may be initially detected on physical exam. Peripheral pulses may be weak and late (sometimes called ''pulsus parvus et tardus''). A harsh systolic crescendo-decrescendo murmur may also be present, which is best heard at the right upper sternal border at the 2nd intercostal space. This murmur may also radiate to the carotid arteries.
 Patients with suspected aortic stenosis should undergo [[Transthoracic echocardiogram]] to confirm the diagnosis and evaluate the severity of the disease. For severe disease, valve replacement therapy should be considered prior to proceeding with elective surgery.
@@ Line 37: / Line 37: @@
 == Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> ==
 == Diagnosis<!-- Describe how this comorbidity is diagnosed. --> ==
 == Treatment<!-- Summarize the treatment of this comorbidity. Add subsections as needed. --> ==

Chris.Rishel at 18:20, 29 January 2021

2021-01-29T18:20:16Z

← Older revision		Revision as of 11:20, 29 January 2021
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	===== Hemodynamics =====		===== Hemodynamics =====

	* '''Hypotension''' should be avoided to preserve afterload (i.e. coronary perfusion pressure). Treat with afterload increasing agents such as [[phenylephrine]].		* '''Hypotension''' should be avoided to preserve afterload (i.e. coronary perfusion pressure). Treat with afterload-increasing agents such as [[phenylephrine]].
	* '''Bradycardia''' should be avoided as these patients are often heart rate dependent to preserve adequate cardiac output. A heart rate of 60-90 bpm is optimal.		* '''Bradycardia''' should be avoided as these patients are often heart rate dependent to preserve adequate cardiac output. A heart rate of 60-90 bpm is optimal.
	* '''Tachycardia''' and '''hypertension''' should be avoided to preserve left ventricular diastolic filling and reduce myocardial oxygen demand. Treat with increasing anesthetic depth or short-acting beta-blockade with [[esmolol]].		* '''Tachycardia''' and '''hypertension''' should be avoided to preserve left ventricular diastolic filling and reduce myocardial oxygen demand. Treat with increasing anesthetic depth or short-acting beta-blockade with [[esmolol]].

	===== Neuraxial anesthesia =====		===== Neuraxial anesthesia =====
	~~Central neuraxial~~ anesthesia is contraindicated in all but mild disease due to the risk of decreased [[systemic vascular resistance]] leading to decreased [[diastolic blood pressure]] and reduced myocardial perfusion		Neuraxial anesthesia is contraindicated in all but mild disease due to the risk of decreased [[systemic vascular resistance]] leading to decreased [[diastolic blood pressure]] and reduced myocardial perfusion

	=== Postoperative management<!-- Describe how this comorbidity may influence postoperative management. --> ===		=== Postoperative management<!-- Describe how this comorbidity may influence postoperative management. --> ===
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	== Related surgical procedures<!-- List and briefly describe any procedures which may be performed specifically to treat this comorbidity or its sequelae. If none, this section may be removed. --> ==		== Related surgical procedures<!-- List and briefly describe any procedures which may be performed specifically to treat this comorbidity or its sequelae. If none, this section may be removed. --> ==

	* [[Aortic valve replacement]]		* [[Aortic valve repair or replacement]]
			* [[Transcatheter aortic valve replacement]]

	== Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. --> ==		== Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. --> ==
			In aortic stenosis, the opening of the aortic valve is narrowed, typically due to calcification from tissue damage over time. The most common cause is valve degeneration in older patients, though stenosis may develop in younger patients with a [[bicuspid aortic valve]]. It is thought that stenosis results from inflammation due to endothelial cell damage from increased mechanical stress.

			As aortic stenosis progresses, higher pressures must be generated by the left ventricle to maintain cardiac output. This initially leads to the development of concentric [[left ventricular hypertrophy]]. In later stages of the disease, the left ventricle dilates and the ventricular walls thin, resulting in reduced systolic function.

	== Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> ==		== Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> ==
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	[[Category:Comorbidity]]		[[Category:Comorbidity]]
			[[Category:Cardiovascular disorders]]
			[[Category:Valvular heart disease]]