Bicuspid aortic stenosis physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Varun Kumar, M.B.B.S. [2]

Overview

Bicuspid aortic valve is often undiagnosed until later in life when the person develops symptomatic aortic stenosis. Aortic stenosis occurs in this condition usually in patients in their 40s or 50s, an average of 10 years earlier than can occur in people with congenitally normal aortic valves. On auscultation, you will hear a mid systolic murmur and a slowed carotid upstroke.

Physical Examination

Heart

• Unlike acquired aortic stenosis (AS), the contour of the carotid pulse is not a good predictor of severity in congenital AS because it is so variable.

Auscultation

Heart Sounds

• Paradoxical splitting of second heart sound, S2 is present in severe aortic stenosis.
• Because the valve is not calcified early on in the case of a fused valve, an ejection click may be present unlike acquired AS.
• As the disease progresses, the ejection sound and the intensity of the aortic component (A2) of the second heart sound (S2) decrease.
• Patients often have an S₄.

Murmurs

• There is a mid systolic murmur from birth (occurs later in life in acquired AS). It is heard best in aortic area (2nd intercostal space along right sternal border).
• In presence of aortic insufficieny, a diastolic murmur may be heard. Various maneuvers such as isometric handgrip, having patients lean forward in a seated position helps in hearing the murmur better.

Other Physical Features Related to Associated Syndromes

• Turner's syndrome:
  • Short stature female
  • Webbed neck
  • Low hairline
  • Broad chest with wide spaced nipples

• William's syndrome:
  • Elfin facies
  • Mild retardation
  • Autism