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begin with aortic stenosis okay so this
refer to a few times how's it patient
feeling walking to the door and your
patient tells you well I'll give you
that patient earlier it was 32 years of
age with aortic stenosis mm-hmm I was
impossible the 32 year old is having
aerodeck stenosis how is it possible
that the aortic valve has already
undergone so much damage that it's now
accumulating dispro for calcification
memory calcification in basic pathology
that we talked about the differences
between dystrophy calcification and
metastatic calcification you've done
that plenty of times what's the
difference dystrophic calcification will
be damaged d dystrophic d damaged tissue
occurs first where is the damaged tissue
here they are ticked off so you have
normal amounts of calcium normal amounts
of calcium that deposits on damaged
tissue resulting in well what kind of
characteristic would calcium then give
that tissue when it starts accumulating
rigid hard so now we have an aortic
valve which is hardened due to disco for
calcification but it still doesn't
answer the question why a 32 year old
why are thirty two old because now your
patient might have been only born with
how many cusps of the aortic valve uno
dos only two how many should it normally
have and where every single valve in the
heart except the oh let me think about
them oh the bicuspid has three three
cusps so now Eric valve Onias - that's
congenital bicuspid disease resulting in
early dystrophic calcification this
patient 32 of your years of age young is
having fatigue and tiredness upon
exertion if there is enough muscle build
up a concentric hypertrophy of the left
ventricular wall may result in angina
maybe even chest pain upon exertion are
you with me
increased afterload tell me about that
murmur why is it where is it located and
where would you hear it second
intercostal space point to it
a right parasternal where else might you
hear it that murmur then may radiate
murmur not the blood will radiate up in
the carotid is that clear
increased pressure mm-hmm so what are we
gonna do with all this we're gonna take
take a look at physiology and with
physio it's important that you take a
look at the take a look at the cardiac
cycle it's important we then compare
this to pressure volume loop is this
important oh my goodness yes and you
know as well as I do as to how often
that is asked on every single level of
medical education there are three main
causes senile calcification so who is
this patient not 32 at 32 year old
probably will not take kindly to the
fact that he or she is going to be
referred to as being senile next Cecina
would have to be someone who's 70 some
right so as we get older our tissues
unfortunately do get tired old damaged
and may result in what kind of
calcification see now disco for
calcification what's our topic
Eric stenosis that'd be the most common
cause obviously can we prevent age from
taking place not that I know of unless
you're Johnny Depp from Pirates of the
Caribbean and he was looking for
Fountain of Youth
you know his entire life got old in the
process though even he was not
successful incidence increases with
advancing age obviously what's happening
they are take valve is becoming damaged
how many cusps misses patient have three
clear three it's just getting old
damaged calcification this is the 32
year old that I've been referring to a
couple of times now
congenital bicuspid aortic valve now
what I do want you to pay attention to
is don't just take a look at congenital
and give it a generic name what kind of
con generatio oh maybe it's Down
syndrome it's a congenital I believe so
what about Turner syndrome X Oh could
you have bicuspid of course these are
all congenital conditions so any
congenital anomaly might then also give
rise to a bicuspid aortic valve and now
prone through what dystrophic
calcification at what age young and by
young were talking 20s and 30s
next what else in developing countries
not developed countries in developing
countries the most common cause of
aortic stenosis would be rheumatic heart
disease is that clear now what do you
want to do with rheumatic heart disease
be careful and the reason I say that is
number one couple ways in which a
patient may develop this and we'll talk
about this in greater detail and
obviously hit upon this in microbiology
and you have a child I might have
pharyngitis and that pharyngitis was
caused by a group a streptococcus a
styptic ox i pyogenes and this
pharyngitis was not properly treated and
two to four weeks later ended up
developing issues in the Horten all
right so we had rheumatic fever part of
this might have been endocarditis right
or maybe it was impetigo
impetigo well it could be caused by
staph but in this case streptococcus
pyogenes and may may give rise to heart
not so much and we'll talk about that
more being with post streptococcal but
at this point what I want to firmly or
plant a seed in your head is the fact
that streptococcal infections do not
only limit it to pharyngitis could also
involve the skin but each one of those
will be giving rise to different types
of diseases so here we go with rheumatic
heart disease if it's early on and
damage to the valve listen what I'm
saying early is the operative word then
it would be a regurgitate of issue
what's my topic a stenosis what do you
think stenosis might mean in a rheumatic
heart disease patient you just caused
damage at some point in time don't you
think that repair process is kicking in
of course it is what does the repair
process mean to you collagen coming in
deposition of fibrosis so what is
fibrosis mean to you hardening is that
clear do not memorize this so when you
talk about romantic heart disease 95
percent of your patients will have
issues with the left-sided heart valves
dr. Raj what about the right side of
course the right side could be involved
with a measly 5 percent so do you want
to spend time on things that are
uncommon why would you want to do that
why would
you want to make your life more
difficult so 95% of time would be the
left side on the left side it would be a
or dick and mitral right so those are
the vows that be effective early on it
be Riegert our topic here is stenosis
where is a patient coming from
developing countries what if it was a
developed country congenital bicuspid or
older 70-some what kind see now are you
putting things together are you creating
differentials based on the history and
demographics every patient here with
calcification nice little cartoon didn't
differentiate between our normal and
then you find calcification how many
customers you see here 1 2 3 so it was
normal and how old was this patient with
presenting with aortic stenosis and
district for classification old has to
be see now three cusps what if you only
find two cusps then it'll be a young
patient guaranteed is that clear here we
only have two cusps we see them this is
a your dick valve this is not the
bicuspid that's the problem and so
therefore at the age of 30 some ends up
developing district for calcification
aortic stenosis and let's go one step
further how's that left ventricle going
to respond please
hypertrophy memory left ventricles
lifting weights and what are the weights
they are texture gnosis what are they
gonna do undergoes hypertrophy what kind
concentric hypertrophy let's go and step
further really mm-hmm
if that left ventricle wall becomes
thick and thick and thickened
conceptualize this what's the size of
the chamber what's the size of the
chamber please reduced when you have
reduced sizes of chamber because of
increased thickness of the left
ventricle wall you cannot accommodate
four more but to come in is that a
diastolic or systolic dysfunction
it's a diastolic dysfunction in fact
clinically speaking there's something
called heart failure with preservation
of your ejection fraction HF heart
failure preservation p EF ejection
fraction so you can actually have heart
failure with aortic stenosis early on
ejection fraction is normal and still
will be around 55% is that clear
talk more about that later we have
discussed that in physio but it's
important that you bring it into play
now
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