By Donald N. Ross B. Sc., M. B., CH. B., F. R. C. S. (auth.)
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Extra resources for A Surgeons’ Guide to Cardiac Diagnosis: Part II The Clinical Picture
In any case of congenital aortic stenosis over the age of twenty-five years, calcification can generally be demonstrated and, when present, it indicates an obstruction at valve level. Conversely, where calcification is absent in this age group, sub-aortic stenosis should be considered. Left ventricular puncture is a useful investigation in assessing the level and severity of aortic stenosis. It is performed by inserting a needle percutaneously into the left ventricle at its apex (vol. I, p. 64).
Breathlessness is moderate. In severe cases there may be syncope or ischaemic pain on exertion - a form of right ventricular angina. When symptoms arise in infancy the obstruction is usually severe. In ordinary circumstances infants and young children present with a systolic murmur only. On examination, patients with pulmonary valve stenosis are said to have a round, moon-like facies with ruddy cheeks. There is no central cyanosis or clubbing unless there is a reversed atrial shunt. The arterial pulse is not remarkable but the venous pulse may show a giant a wave due to the vigour of the right atrial contractions.
This is due to the fact that right ventricular ejection continues well after the unobstructed left ventricular ejection phase is complete (fig. 43 Vol. I). The closure of the stenosed pulmonary valve is late and not generally audible. This combination of an aortic second sound lost in the murmur, with a very soft or inaudible pulmonary element, gives the impression of an 'absent' second sound at the base. In contrast, cases of Fallot's tetralogy usually have a short harsh murmur and a loud aortic second sound.
A Surgeons’ Guide to Cardiac Diagnosis: Part II The Clinical Picture by Donald N. Ross B. Sc., M. B., CH. B., F. R. C. S. (auth.)