Aortic Stenosis
chronic valvular heart diseaseÀÇ 1/4À» Â÷ÁöÇϸç symptomatic valvular ASÀÇ 80%°¡ ³²¼º
ÀÌ´Ù
1. ¿øÀÎ
congenital : Ãâ»ý½Ã ÀÌ¹Ì stenoticÇϰųª congenitally deformed(bicuspid)
rheumatic : mitral valve¿Í ÈçÈ÷ µ¿¹Ý
degenerative calcification; senile or sclerocalcific AS- ºÏ¹Ì, ¼À¯·´¿¡¼ °¡Àå ÈçÇÑ ¿øÀÎ
* LV outflow obstructionÀ» ÀÏÀ¸Å°´Â ´Ù¸¥ ÇüÅÂ
i) HCM - subaortic stenosisÀ¯¹ß
ii) discrete congenital subvalvular AS
: aortic valve¹Ù·Î ¾Æ·¡ membranous diaphragm or fibrous ridge
iii) supravalvular AS
2. º´Å»ý¸®
¼¼È÷ ÁøÇàÇϸé concentric LV hypertrophy¿¡ ÀÇÇØ LV outputÀÌ À¯ÁöµÈ´Ù.
* critical LV outflow obstruction
: peak systolic pressure gradient > 50 mmHg
or aortic orifice < 0.5cm2/m2
LVEDP°¡ Áõ°¡Çϰí LA pressure¿¡ large a wave(+)
severe AS´ëºÎºÐ¿¡¼ rest½Ã¿£ C.OÀÌ Á¤»óÀÌÁö¸¸, exerciseµ¿¾È¿£ Á¤»óÀûÀ¸·Î Áõ°¡ÇÏÁö
¸øÇÑ´Ù.
º´ÀÇ ¸»±â¿¡ C.O, LV-aortic pr gradient°¡ °¨¼ÒÇÏ¿© mean LA, PA, RV pr°¡ Áõ°¡ÇÑ´Ù.
LV hypertrophyµÇ¸é »ê¼Ò¿ä±¸·®ÀÌ Áõ°¡ÇÏ¿© tachycardia¶§ ischemia°¡ ¹ß»ýÇÑ´Ù.
(ƯÈ÷ subendocardium)
AS´Â MRÀ» ¾ÇȽÃŲ´Ù. ¡ñ LV-> LA·Î pressure°¡ Áõ°¡Çϱ⠶§¹®
3. Áõ»ó
´ëºÎºÐ ¼ö³âµ¿¾È ¼¼È÷ obstructionÀÌ Áõ°¡ÇÏÁö¸¸ Áõ»óÀº 50-60´ë¿¡ »ý±ä´Ù.
* 3 cardinal sx
: exertional dyspnea, angina pectoris, and syncope
i) dyspnea
compliance°¨¼Ò(and/or LV dilatation°¨¼Ò) -> LA, LV diastolic pr¡è
-> pul. capillary pr¡è
ii) AP
hypertrophied myocardium - »ê¼Ò¿ä±¸·®¡è, coronary a. disease + compression
iii) exertional syncope
exercising m.ÀÇ vasodilatation¿¡ ÀÇÇØ arterial pr¡é
nonexercising m.ÀÇ inadequate vasoconstriction
arrhythmia¿¡ ÀÇÇØ sudden C.O¡é
AS, MS°øÁ¸½Ã¿¡´Â MS¿¡ ÀÇÇØ C.OÀÌ °¨¼ÒµÇ¹Ç·Î aortic pressure gradient°¡ °¨¼ÒµÈ´Ù.
µû¶ó¼ AS¿¡ ÀÇÇØ ³ªÅ¸³ª´Â ¸¹Àº clinical findingsÀÌ MS¿¡ ÀÇÇØ maskingµÈ´Ù.
4. Physical findings
AF(+) : mitral valve diseaseµ¿¹Ý °¡´É¼º ½Ã»ç
systolic BP : Á¤»ó, ¸»±â¿¡´Â S.VÀÌ °¨¼ÒÇÏ¸é¼ BP°¡ ¶³¾îÁö°í pulse pr´Â Á¼¾ÆÁø´Ù.
peripheral a. pulse(carotid or brachial a.)
õõÈ÷ Áõ°¡ÇÏ¿© delayed sustained peak¿¡ µµ´Þ = pulsus parvus et tardus
cf. bisferiens pulse(=palpable double systolic arterial pulse) => AR
JVP¿¡¼ÀÇ a wave¡è
* ûÁø
early systolic ejection sound(AV opening snap)
- noncalcific valvular AS¿¡¼ µéÀ»¼ö ÀÖÀ¸¸ç calcified & rigidÇÒ¶© ¼Ò½ÇµÈ´Ù.
ASÁ¤µµ°¡ ½ÉÇØÁü¿¡ µû¶ó aortic valvue closure°¡ ¿¬ÀåµÇ¾î pulmonic valve closure¿Í
µ¿½Ã¿¡ ÀϾ°Å³ª µÚ¿¡ ³ªÅ¸³ª paradoxic splitting of S2¸¦ ¾ß±âÇϱ⵵ ÇÑ´Ù.
S4 : LVHÁ¸Àç, LVEDP¡è¸¦ ÀǹÌ
S3 : LV dilatationÀǹÌ
AS murmur ; ejection (mid)systolic murmur, S1Á÷ÈÄ
ejectionÁß°£±îÁö intensityÁõ°¡
aortic valve closureÁ÷Àü¿¡ Á¾·á
low-pitched, rough, and rasping in character
base¿¡¼ °¡Àå Å©°Ô µé¸°´Ù(mc 2nd Rt intercostal space)
5. Lab
1) ECG : LVH
ÁøÇàµÇ¸é ST depression & T-wave inversion in lead I, aVL, Lt precordial
lead(LV "strain")
2) roentgenogram
concentric LVH
critical AS = poststenotic dilatation of the ascending aorta
"valvular calcificationÀÌ ¾ø´Ù¸é severe AS´Â ¾ø´Ù"
3) Echo
Doppler echo - transaortic valvular pr gradient
4) catheterization
Ix i) AS sx + myocardial ischemia sx(coronary a. diseaseµ¿¹Ý ÀǽɽÃ)
-> CABG °°ÀÌ ÇØ¾ß ÇÒÁö ÆÇ´Ü
ii) multivalvular ds
°¢°¢ÀÇ valvular deformity°¡ Áõ»ó¿¡ ±â¿©ÇÏ´Â ¿ªÇÒÀ» Á¶»çÇÏ¿© ¼ö¼ú°èȹ¿¡
µµ¿òÀ» ÁØ´Ù.
iii) young, asymptomatic pt with noncalcified congenital AS
-> LV outflow severity¸¦ Æò°¡.
ºñ·Ï ¹«Áõ»óÀÌÁö¸¸ severe ASÀÇ °æ¿ì¿¡ ¼ö¼úÀÌ ÇÊ¿äÇÒÁö ¾Æ´Ï¸é
balloon valvotomy°¡ ÇÊ¿äÇÒÁö °áÁ¤
iv) LV outflow obstructionÀÌ ÀǽɵÇÁö¸¸ aortic valveº¸´Ù´Â sub- or supravalvular
regionsÀ̶ó°í »ý°¢µÉ ¶§
6. ÀÚ¿¬°æ°ú
´ëºÎºÐ 60-70´ë¿¡ »ç¸ÁÇϰí Áõ»ó ¹ß»ýÈÄ »ç¸Á±îÁöÀÇ Æò±Õ ±â°£Àº
AP: 3³â, syncope: 3³â, dypnea: 2³â, CHF :1.5-2³â
80%À̻󿡼 Áõ»ó ¹ß»ýÈÄ »ç¸Á±îÁö´Â 4³â¹Ì¸¸.
CHF°¡ ÁÖµÈ »ç¸Á¿øÀÎÀÌ´Ù(1/2-2/3).
sudden death ; arrhythmia(Æò±Õ 60¼¼, 10-20%), ÀÌ·± ȯÀÚ´Â ´ëºÎºÐ Áõ»óÀÌ ÀÖ´Â »óÅÂ.
7. Ä¡·á
i) severe AS : strenous physiologic activity¸¦ ÇÇÇÒ °Í. ºñ·Ï ¹«Áõ»óÀ̶ó ÇÏ´õ¶óµµ.
ii) HF(+) : digitalis, sodium restriction
diuretics´Â Á¶½É½º·´°Ô »ç¿ëÇÏ¿© volume depletionÀ» ÇÇÇÒ °Í.
* vasodilator´Â °ÅÀÇ µµ¿òÀÌ µÇÁö ¾Ê°í ¿ÀÈ÷·Á ÇØ·Ó´Ù.
iii) AP(+) : NTG
¨ç surgical tx
calcific As + critical obstruction(aortic orifice < 0.5cm2/m2) => AVR
severe calcific AS + asymptomatic => ¼ö¼ú¿¬±â
Áõ»óÀÌ ¹ß»ýÇÏ´ÂÁö ÁÖÀDZí°Ô °üÂûÇϰí
LV fxÀÌ ¾ÇȵǴÂÁö serial echo F/U
°¡´ÉÇϸé frank LV failure°¡ »ý±â±â Àü¿¡ ½ÃÇàÇØ¾ß ÇÑ´Ù.
¸»±â¿¡´Â ±â¼úÀûÀ¸·Î ¼º°øÇÏ´õ¶óµµ myocardial ds°¡ Á¸ÀçÇÒ¼ö Àֱ⠶§¹®ÀÌ´Ù.
long-term postop survivalÀº preop LV dysfunctionÁ¤µµ¿Í ¹Ýºñ·ÊÇÑ´Ù.
10YSR = 60%
bioprosthetic valveÀÇ 30%¿¡¼ 10³â³» primary valve failure -> re-replacementÇÊ¿ä
mechanical valveÀÇ °æ¿ì¿¡µµ ºñ½ÁÇÑ ºóµµ·Î hemorrhagic cx¹ß»ý.
¨è percutaneous balloon aortic valvuloplasty
children, young adults with congenital, noncalcific AS¿¡¼ ÀûÇÕ.
elderly with severe calcific AS´Â ÈçÇÏ°Ô »ç¿ëµÇÁö´Â ¾Ê´Â´Ù(¡ñhigh restenosis rate)
=> ±×·³¿¡µµ ºÒ±¸Çϰí ÀÌ·± ȯÀڵ鿡°Ô¼ ¼ö¼úÇϱ⿡´Â ³Ê¹« »óŰ¡ ¾ÈÁÁ°í
life-threatening AS°¡ ÀÖÀ» ¶§ opÀü¿¡ bridge¿ªÇҷμ ½ÃÇàÇÒ¼ö ÀÖ´Ù.
("bridge to operation")