Pediatric Supravalvar Aortic Stenosis Clinical Presentation
- Author: Anita Krishnan, MD; Chief Editor: Howard S Weber, MD, FSCAI more...
Symptoms caused by SVAS usually develop in childhood. Rarely, symptoms may develop in infancy; in some cases, symptoms develop in the second or third decade of life.
Most pediatric patients present because of a heart murmur or the features of Williams syndrome. Patients with Williams syndrome may also develop systemic hypertension and involvement of joints, peripheral pulmonary artery stenosis, coarctation of aorta, and mitral insufficiency.
Dyspnea on exertion, angina, and syncope develop in the course of the disease if SVAS is untreated. These symptoms indicate at least a moderate degree of LVOT obstruction. Because of the coronary artery involvement, angina may arise early and more often than in other obstructive LVOT lesions. Because of the risk of sudden death in SVAS, the development of angina and syncope should prompt immediate investigation.
The physical examination focuses on upper extremity pulses, the precordium, heart sounds, and heart murmurs.
Asymmetrical upper extremities pulses
Discrepancies between carotid pulsations and upper extremity pulses and blood pressure are the characteristic clinical findings in SVAS. The discrepancies occur because the jet of blood flow from SVAS has a preferential trajectory into the brachiocephalic (innominate) artery (ie, Coanda effect).
The precordium is usually hyperdynamic, and the apex of the heart is displaced laterally and inferiorly because of ventricular hypertrophy. A thrill in the suprasternal notch is usually felt because of the trajectory of the blood flow jet from SVAS.
The first heart sound is generally normal. A narrowly split, single, or paradoxically split second heart sound and a fourth heart sound are present in severe SVAS.
The characteristic systolic murmur of SVAS is crescendo-decrescendo in shape, low pitched, and best heard at the base of the heart, sited higher than in valvular aortic stenosis. It mainly radiates to the right carotid artery and tends to peak during the last two thirds of ventricular systole if the obstruction is severe.
A high-pitched, short, early diastolic aortic regurgitation murmur is uncommon in SVAS unless the aortic valve has become damaged due to the supravalve obstruction and has become regurgitant. An ejection click is absent.
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