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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» ¾ÇÈ­½ÃŲ´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 °¨¼ÒÇϸ鼭 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 ¾ÇÈ­µÇ´ÂÁö 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")