See [[Valvular disorders#Aortic stenosis|Valve disorders → Aortic stenosis]]. [[ECHO]] [Harrison’s Aortic Stenosis](x-devonthink-item://D7D7DEE3-8F19-43B8-9F8B-9722C906DAB6?page=2018) # Factoids - most common isolated valve lesion - men > women - harsh ejection systolic murmur peaks mid systole. radiates to carotids. prominent S4, soft A2. ejection click early systole - may have narrow [[Pulse pressure]] with severe AS - [Heyde's syndrome](https://en.wikipedia.org/wiki/Heyde%27s_syndrome) is a syndrome of GI bleeding from angiodysplasia in the presence of aortic stenosis # intubation and RSI with aortic stenosis | consideration | management | | --------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------- | | Goals | - keep HR 60 (faster if a/w regurg)<br>- avoid hypotension | | prepare | - ?awake intubation<br>- optimise haemodynamics, maintain *diastolic BP*<br>- small fluid bolus<br>- metaraminol vasopressor of choice<br>- maintain sinus rhythm | | position | upright | | pre-oxygenation | avoid PEEP | | drugs | - avoid tachycardia and hypotension<br>- consider 3-5mg/kg fent + midaz + roc only | | intubation | normal | | failure? | pads ready if cardiac arrest | ***Goals*** - keep HR slow (~60-90) and in sinus rhythm - need diastole for artery filling - tachycardia increases myocardial O2 demand → ischaemia - if AS occurs with regurg, you can allow a higher rate - avoid hypotension - reliant on high filling pressures; if decreased → ↓ EDV (preload) → reduced cardiac output, reduced coronary perfusion pressure → ischaemia - if diastolic falls too low, the coronary arteries will not get enough filling ***Prepare*** - consider awake intubation - maintain diastolic blood pressure - small fluid bolus (too much can cause RV failure) - **metaraminol** , **noradrenaline**, and phenylephrine are vasopressors of choice (maintain diastolic BP) - maintain sinus rhythm - avoid diuretics and vasodilators (especially venodilators like GTN) - avoid anything that impairs contractility like beta blockers or CCB (increased myocardial contractility is the mechanism of adjustment to extreme valve narrowing) - digoxin is OK ***Position*** - upright ***Pre-oxygenation**** - avoid PEEP ***Drugs*** - avoid tachycardia and hypotension - consider 3-5 mcg/kg fent + midaz + roc only ***Intubation*** usual ***Prepare for failure*** - pads