대동맥

순환기내과 손 일 석

대동맥

판막 질환

학습목표 (한국의과대학장협의회,2006)

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References

 Harrison's Principles of Internal Medicine, 19^th ed

 Braunwald’s Heart Disease, 10^th ed

심장의 판막

대동맥판

2D Echo of aortic valve

RCC LCC NCC

Etiology of Valvular Heart Disease

Rheumatic

 Post-inflammatory : rheumatic fever – carditis

 Rheumatic fever : dominant cause of valvular heart disease in developing and low-income countries

 Mitral > aortic > tricuspid > pulmonic

Degenerative

 Aortic valve sclerosis & stenosis

 aging ± atherosclerosis

 Mitral annular calcification (MAC)

 Myxomatous degeneration

 mitral valve prolapse (MVP)

대동맥판 협착증

Aortic Stenosis

대동맥판협착증 원인

~80% : male

Etiology

 Degenerative calcific AS : m/c

 Rheumatic : a/w mitral valve, w/ AR

 Congenital (bicuspid, unicuspid)

LV outflow obstruction

 Hypertrophic obstructive cardiomyopathy (HOCM)

 Subvalvular AS (subaortic stenosis)

 Supravalvular AS

atherosclerosis

From Otto CM: Calcific aortic stenosis—time to look more closely at the valve. N Engl J Med 359:1395, 2008.

Degenerative Calcific AS

Rheumatic vs degenerative AS

• Aortic sclerosis/stenosis in degenerative valve

• No commissural fusion

• Leaflet thickening in the body

• Aortic stenosis in rheumatic valve

– Commissural fusion

– Leaflet thickening along the leaflet closure – a/w rheumatic mitral valve, with regurgitation

Rheumatic vs Degenerative

Bicuspid AV (BAV)

Pathophysiology

LV outflow obstruction

 Δ P between LV and aorta

 Adaptive mechanism: Laplace law (S=P*r/h)

 concentric LVH

 LV dysfunction

Severe obstruction

• Mean systolic PG > 40mmHg with normal CO

• Effective AV area < 1 cm² (~1/3 of normal)

Pathophysiology

Symptoms

No Sx until 50~70s

cf. BAV 1-2 decades sooner sx

3 cardinal Sx

 Angina pectoris

 Syncope

 Exertional dyspnea

Time to death

 Angina, syncope : 3 yrs

 Dyspnea : 2yrs

 CHF : 1.5~2 yrs

Diagnosis

Arterial pulse



pulsus parvus et tardus

(rises slowly to a delayed peak)

Auscultation

 (mid) systolic ejection m.

ECG

 LVH strain

Echocardiogram

 Concentric LVH, LV dysfunction

 Calcific valve, bicuspid, AV area (severity)

Low-pitched, rough and rasping

loudest at the base of the heart (2^nd Rt ICS) transmitted upward along the carotid arteries

http://www.sharinginhealth.ca/clinical_assessment/heart_sounds.html

Cardiac Auscultation

Aortic stenosis

96

Cardiac Catheterization

Aortic stenosis

J Am Coll Cardiol 63:e57: 2014

Operation (AVR) Indication

Severe AS (valve area <1 cm

or 0.6 cm

/m

BSA) who are symptomatic

LV systolic dysfunction (EF <50%)

Asymptomatic moderate or severe AS who are referred for CABG

BAV disease and an aneurysmal root or ascending aorta



Prosthetic valves

PABV

- 주로 소아청소년 - bridge to operation - 재협착, 합병증 위험 - part of TAVR

Percutaneous Aortic Balloon Valvuloplasty

Transcatheter Aortic Valve Implantation (TAVI) or Replacement (TAVR)

Self-expanding AV prosthesis: the CoreValve

2015.국시.3교시.홀수형.29번

83세 남자가 3달 전부터 가슴이 아프고 숨이 차서 병원에 왔다. 30년 전부터 혈압강하제를 복용하였다. 혈압은 116/64 mmHg, 맥박 86회/분이었다. 가슴 청진에서 복장뼈 오른쪽 옆 두 번째 갈비사이에서 III/VI도의 박출 수축기 잡음이

들렸고, 목동맥과 심장끝에서 수축기 잡음이 들렸다.

심전도와 가슴 X선 촬영에서 좌심실 비대가 있었다. 환자와 가족이 개흉 수술을 거부하였다. 치료는?

1) 승모판클립 삽입

2) 동맥관열림증 가리개(occluder) 삽입 3) 카테터경유대동맥판막 삽입

4) 심방사이막결손 가리개 삽입 5) 왼심방귀 가리개 삽입

Harrison 19th. Chaper 283. aortic valve disease

대동맥판 역류증

Aortic Regurgitation

Etiology of AR

Primary valve disease

 Rheumatic : ~2/3

 Congenital, e.g. bicuspid

 Degenerative, calcific

 Prolapse (±VSD), myxomatous, endocarditis

Primary aortic root disease

 Marfan syndrome, cystic medial necrosis

 Aortic dissection

 Degenerative, syphilis, ankylosing spondylitis

Waller. Cardiovasc Clin 1986

Rheumatic AR

Prolapse

Infective endocarditis

Marfan’ syndrome

Aortic Regurgitation

Normal Acute AR

Chronic compensated AR Chronic decompensated AR

 SV

 HR

 LVEDP

 EDV

 SV

 LVEDP

 EDV

 SV, EF

 LVEDP

Diagnosis

Arterial pulse

 pulsus bisferiens

 Corrigan’s pulse : “water-hammer” pulse

 Quincke’ s pulse : nail root

 Traube’ sign, Duroziez’ sign over femoral a.

 Wide pulse pressure

Auscultation

 Decrescendo diastolic m.

 (mid) systolic ejection m.

 (mid) diastolic Austin Flint m.

Chronic AR Acute AR

AF: Austin Flint murmur ^↓SEM : ↓forward SV

↓S1 : premature closure of MV

Inspection:

• bounding (Corrigan’s) pulse

• head bobbing (Musset’s sign)

• compare with normal carotid

Auscultation:

• “To-fro” murmur – Midsystolic murmur – Early diastolic murmur

• 3RICS

– “To-FRO”

• 2RICS – “TO-fro”

Aortic Regurgitation

Chronic:

• at Base:

– MSM (Ao outflow)

– EDM (Ao regurgitation)

• at Apex:

– Austin Flint (mitral inflow)

– “split” S1 (S1 + ejection sound)

Acute:

• at Base:

– MSM (Ao outflow) – EDM is abbreviated

• at Apex:

– Austin Flint (mitral inflow)

– absent S1 (ejection sound only)

Chronic vs. Acute

Aortic Regurgitation

J Am Coll Cardiol 63:e57: 2014

Treatment of AR

Acute AR

 iv diuretics, vasodilators

• beta-blocker, IABP  contraindicated !

 in acute severe AR, surgery is TOC

Chronic AR

 iv diuretics, vasodilators

 Severe symptomatic AR  surgery (AVR)

Aortic Valve Disease

Aortic stenosis

 Degenerative, Rheumatic, Bicuspid

 Concentric LVH

 Angina, syncope, dyspnea

Aortic regurgitation

 Valvular (rheumatic..) vs aortic root

 LV dilatation and LV hypertrophy