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By Michael Y. Henein MSc, PhD, Mary Sheppard MD, FRCPath, John Pepper M.Chir, FRCS, Michael Rigby MD, FRCP (auth.)

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Calcific aortic stenosis is an increasingly important disabling problem in an aging population, affecting 2% of people more than 65 years of age. 10 Pathophysiology Significant aortic stenosis with a pressure drop in excess of 70 mmHg represents a fixed resistance to left ventric- ular ejection. It results in increased stroke work and hence hypertrophy that may be greater than in the coronary vascular bed, leading to subendocardial ischemia and later fibrosis. The latter is a progressive condition that leads to increased ventricular predisposition to dysfunction and arrhythmias.

28. A pathology section from a patient with infective endocarditis with leaflet perforations causing aortic regurgitation. 29. Transesophageal echocardiogram from a patient with severe aortic regurgitation secondary to bacterial endocarditis. Note the abscess cavity in the aortic root that changes its size and shape during the cardiac cycle; systole (left) and diastole (right). the former the flap tends to hold the cusps opened in diastole, the dissection and false lumen in the latter tend to disturb the normal aortic vortices that close the valve cusps in early diastole.

40. Mitral valve echogram from a patient with acute aortic regurgitation showing early diastolic mitral valve closure (top) and timerestricted filling (bottom). A ··-······································-············· •• I . ... t 1 . ~J-, t " ~, 1 , f r. 41. An apexcardiogram from a patient with significant acute aortic regurgitation. Note the increase in end-diastolic pressure over the course of 12 months. 50 I 2: Aortic Valve volume will result in raised diastolic pressures with its subsequent additional effect on subendocardial blood flow and function.

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