Aortic stenosis - case report
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Transcript of Aortic stenosis - case report
Case presentation
Diana Girnita, MD, PhD
The Christ Hospital
CC: chest pain
HPI:
• 64 yo WM admitted for chest pain that
started about 2 years ago; became
progressively worse, initially appeared with
walking aprox 1 mile and progress to less
then 1 block.
• CP described as pressure in his mid-
chest, always with exertion, nonirradiating,
rated as 6-7/10, attenuated by rest,
accompanied by DOE.
• Denies palpitations or syncopal episodes.
ROS
• No fevers, chills, or weight loss.
• Skin: Skin, hair, nail changes. No rash or pruritus
• Neurologic: No syncope, weakness, seizure ,
headaches/ gait abnormalities.
• Eyes: No blurred vision
• ENT: No hearing loss. No epistaxis, nasal discharge.No
bleeding gums, or sore throat
• CV: ++ CP,+ SOB, No palpitations/no claudication.
• Respiratory: + SOB, no wheezing, +dry cough, denies
asthma, COPD or chronic bronchitis
• GI: No change in appetite, dysphagia, nausea, vomiting,
constipation, diarrhea
• Psychiatric:+anxiety. No memory loss or AMS
PMHx
• CAD (coronary artery disease)
• Hypertension
• Hyperlipidemia
• Diabetes mellitus type II
• Depression with anxiety attacks
• Obesity
Social History
• Married, 2 kids
• Farmer
• Never a smoker
• Alcohol: 2 beers/ night
Home medication
• insulin (HUMULIN 70/30) and Insulin Detemir
• lorazepam 0.5 mg PO tablet
• NORTRIPTYLINE 30 mg PO
• CHOLECALCIFEROL, VITAMIN D3, PO
• amlodipine-benazepril 10-40mg PO
• aspirin 81 mg PO
• Clopidogrel 300 mg PO
• Esomeprazole 20 mg PO
• irbesartan-hydrochlorothiazide (AVALIDE) 150-
12.5 mg PO BID
• Nebivolol 10 mg PO Tab
• simvastatin (ZOCOR) 40 mg PO.
Vital signs
• BP 146/58
• Pulse 82
• Temp 98.6 °F (37 °C) (Oral)
• Resp 20
• Ht 6' 2" (1.88 m)
• Wt 285 lb 9.6 oz (129.547 kg)
• BMI 36.67 kg/m2
• SpO2 97%
Physical examination
• Constitutional: NAD
• HEENT: NC/AT, EOMI, PERLA, normal bilateral external
ears, oropharynx and nose
• Neck: Normal ROM, No JVD, carotid upstrokes are
preserved without audible bruits.
• Cardiovascular: RRR, S1&S2 normal. 2/6 Systolic
crescendo-decrescendo murmur present in right 2nd ic
area, no galops or rub.
• Lungs: CTA, bilateral crackles in the bases
• GI: Soft, NT, BS normal, No pulsatile masses.
• Extremities: Intact distal pulses, No edema
• Neurologic: AO x 3, Normal motor and sensory function,
No focal deficits.
• Skin: Warm, Dry, No erythema, No rash.
• Psychiatric: Normal affect and mood
Labs
• WBC 9.6
• RBC 4.68; Hb 15.5; Ht 43.4, MCV
93.2
• Platelets 294
• BNP 278
• Na 135; K 3.8; Cl 99; CO2 22;
• BUN 17, Cr 1.32; GFR 55
• Chol 141, HDL 63, LDL 58, TG 98
• Glucose 308
• TSH 1.42
EKG
CXR
• Stable cardiomegaly.
• Mediastinal contours unremarkable.
• No pulmonary infiltrate or pleural
effusion.
• Pulmonary vessels within normal
limits.
IMPRESSION:
No acute disease
ECHO
• LV: The cavity size was normal. There was mild
concentric hypertrophy. Systolic function was normal.
The estimated EF: 50% to 55%. Severe hypokinesis of
the mid-distalanteroseptal myocardium. Mild
hypokinesis of the lateral myocardium.
• abnormal LV (grade 1 DD).
• Aortic valve: Moderate focal thickening and calcification.
Cusp separation was markedly reduced. There was
severe stenosis. Mean gradient: 32mm Hg (S). Peak
gradient: 68mm Hg (S). Valve area: 0.88cm^2(VTI).
Valve area: 0.83cm^2(Vmax). Aorta: Aortic root
dimension: 50mm (ED, M-mode).The aortic root was
dilated.
• LA: The atrium was moderately dilated.
Previous heart investigations
• 2008: Heart cath- CAD -inf isch, 70% m
LAD, 70%ndom RCA.
• 2010: Lexi scan that revealed EF 60%,
normal coronary perfusion.
• 2009 Carotid duplex: 20 - 49% Right ICA,
< 20% Left ICA, Vertebral: Bilateral
Antegrade Flow
Heart catheterization during this admission
Right and Left Heart
Catheterization and
Hemodynamics
Right atrium 13/13/11
Right ventricle 51/9
Pulmonary artery 40/22/31
Pulmonary artery wedge 21/24/19
Left ventricle 157/34
Aorta 106/59/79
Peak
gradient
(mm Hg)
Mean
gradient
(mm Hg)
Valve area
(thermodilution)
(cm2)
Valve area
(Fick)
(cm2)
Aortic
valve
51 39 1.04 0.99
Left ventriculography
Estimated EF
Wall motion
30%
Anteroapical hypo-akinesis and inferoapical
dyskinesis
Valve function No definite MR is seen.
Coronary
angiography
Dominance left
Left Main normal
LAD Courses to the undersurface of the apex and gives rise to
a large diagonal branch. There is 90%focal early mid
LAD stenosis.
Left Circumflex Supplies 2 obtuse marginal branches and posterior artery
branch and the PDA. There is diffuse 80% stenosis at the
distal end of the first obtuse marginal branch there is
50% focal proximal stenosis of the LPDA
Right There is hazy 70% ostial stenosis and 70% mid stenosis
of the nondominant RCA
Aortic stenosis-
management
Etiology of valvular AS
• Congenitally abnormal valve
with superimposed calcification
(uni/ bicuspid)
• Calcific disease of a trileaflet
valve
• Rheumatic valve disease
• Rare causes include metabolic
diseases (Fabry's disease),
SLE, Paget disease, CKD
Normal aortic valves
effective area of valve opening =
cross-sectional area of LV tract
(3.0 to 4.0 cm2 )
Normal Bicuspid valve Geriatric valve
Pathophysiology
• Ao valve sclerosis: no significant gradient (Aojet velocity ≤2.5 m/sec)
• Aortic stenosis - antegrade velocity across an abnormal valve is at least 2.6 m/sec.
• When AS becomes hemodynamicallysignificant, it results in obstruction to LV and LV adaptive changes (concentric hypertrophy);
• LVEDV are maintained for a prolonged period despite a systolic pressure gradient between the LV and peripheral arterial system
• Symptoms occur when valve area is <1.0 cm2, the jet velocity is over 4.0 m/sec, and/or the mean transvalvular gradient exceeds 40 mmHg
Classic symptoms
1. decreased exercise tolerance and
dyspnea on exertion (Heart failure)
2. Syncope or dizziness
3. Angina
Physical examination
• A slow rate of rise in the carotid pulse
• S2 is soft and single (A2 is delayed and
tends to occur simultaneously with P2)
• S2 may become paradoxically split when
the stenosis is severe and associated with
LV dysfunction
• S1 is usually normal
• Vigorous left atrial contraction can lead to
a fourth heart sound (S4).
Aortic Stenosis: Physical Findings
S1 S2 S1
S2
Mild-Moderate Severe
An early peaking murmur is typical for mild to moderate AS
Late peaking murmur is consistent with severe AS.
Investigations
• ECG
• CXR
• Exercise testing
• Echocardiography
• Coronary angiography
AS severity
Severity Mean gradient,mm Hg
Aortic valvearea, cm2
Mild <25 >1.5
Moderate 25-40 1.0-1.5
Severe >40 <1.0
Critical >80 <0.7
Question 1
Which of the following parameters is NOT
helpful in determining the need for
surgery in severe chronic aortic
regurgitation (AR)?
A. Decreasing exercise tolerance
B. Left ventricular (LV) end-systolic
diameter
C. Severity of pulmonary hypertension
D. LV end-diastolic diameter
E. LV ejection fraction
Answer:
Answer: C. Severity of pulmonary
hypertension. Indications for AVR in
patients with severe chronic AR include
onset of symptoms, worsening exercise
tolerance, declining EF, and severe LV
dilatation. Unlike mitral valvular disorders,
pulmonary hypertension is not usually a
prominent feature of chronic AR except in
the late stages when the decompensated
ventricle leads to congestive heart failure.
ACC/AHA 2008 –ECHO recommendations
Class I
• diagnosis and assessment of AS severity
• assessment of LV wall thickness, size, and function
• re-evaluation of patients with known AS and changing symptoms or signs.
• assessment of changes in hemodynamic severity and LV function in patients with known AS during pregnancy.
• re-evaluation of asymptomatic patients: every year for severe AS; every 1 to 2 years for moderate AS; every three to five years for mild AS
• measurement of jet velocity and calculation of the left ventricular-aortic gradient and the valve area
• Ao regurgitation (80%)
Question 2
• A 75-year-old man is referred to you for evaluation of his first syncopal episode. He does not recall any seizure-like activity associated with the episode. He reports no palpitations, chest pain, orthopnea, or lower extremity edema. He has led a rather sedentary life since his wife passed away 5 years ago. His physical examination is significant for normal BP and HR and a crescendo-decrescendo murmur at the right upper sternal border radiating to the carotids. The murmur sounds late peaking in systole, and A2 is diminished. TTE shows LVH with preserved LV function and aortic stenosis (AS) with an estimated aortic valve gradient of 65 mm Hg. Which of the following tests would be the most appropriate next step?
A. Transesophageal echocardiography (TEE)
B. Dobutamine stress echocardiography
C. Holter monitoring
D. Coronary angiography
E. Electrophysiology study
Answer
Answer: D Coronary angiography- This
patient needs an AVR. He should have
a preoperative cardiac catheterization
to determine the need for concomitant
CABG.
ACC/AHA 2008 -Cardiac catheterization
recommendation
Class I
• patients with AS at risk for CAD
• at the time of aortic valve replacement to identify patients who might also benefit from coronary artery bypass graft surgery
• symptomatic patients in whom noninvasive tests are inconclusive or provide discrepant results from clinical findings regarding the severity of aortic stenosis
• risk of cerebral embolization associated with crossing the Ao valve in patients with severe calcific aortic stenosis
Medical Treatment
• Antibiotic prophylaxis is NOT recommended
in all pts with AS for prevention of infective
endocarditis.
• Caution with diuretics and vasodilators
(reduce preload)
• HTN should be treated cautiously with
appropriate antihypertensives (preload
dependence)
• Statins have been studied to see if they
cause regression or delayed progression of
leaflet calcification (need more data)
Question 3
• An 89 yo F is evaluated during a routine examination.
She maintains her exercise regimen, which includes
walking three or four times per week, but notes that she
is more easily fatigued than she used to be. It takes her
almost an hour to walk her current route, which took 25
to 30 minutes a year ago, and she occasionally has to
pause to catch her breath. She denies angina,
presyncope, syncope, or pedal edema. PMHx:
hypertension and osteoporosis. She is currently taking
hydrochlorothiazide, lisinopril, alendronate, calcium, and
a multivitamin.
Question 3 -continuation
• PE: temp-normal, BP- 148/90 mm Hg, HR- 82/min.
Estimated CVP is 4 cm H2O. There is a sustained apical
impulse. S1 is normal. There is a single S2 and an S4 but
no S3. A grade 3/6 late-peaking systolic murmur is heard
best at the right second intercostal space, with radiation
into the right carotid artery. Carotid artery upstrokes are
delayed. Lungs are clear.
• TTE shows concentric LVH and normal systolic function.
There is a trileaflet aortic valve with heavy calcification.
Aortic jet velocity is 4.8 m/s, peak transaortic gradient is
92 mm Hg, and valve area is 0.7 cm2.
Question 3- continuation
Which of the following is the best
management option?
A. Aortic balloon valvuloplasty
B. Aortic valve replacement
C.Discontinue hydrochlorothiazide and
begin furosemide
D.Clinical follow-up in 1 year
Answer:
• Correct answer: B- in severe, symptomatic
aortic stenosis, AVR improves long-term
survival and quality of life.
Effective treatments for severe AS.
1. Surgical replacement of
the aortic valve
2. Transcatheter aortic
valve replacement
(TAVR)
ACC/AHA 2008 Indications for Aortic Valve
Replacement (AVR)
Class I
1. symptomatic patients with severe AS.
2. patients with severe AS undergoing
CABG or surgery on the aorta or other
heart valves.
3. patients with severe AS and LV
systolic dysfunction (EF < 0.50)
ACC/AHA 2008-Aortic Balloon Valvotomy
Class IIb
1. reasonable as a bridge to surgery in hemodynamically unstable adult patients with AS who are at high risk for AVR
2. reasonable for palliation in adult patients with AS in whom AVR cannot be performed because of serious comorbidities
Class III –NOT recommended as an alternative to AVR in adult patients with AS; pregnancy may be an exception
Transcatheter aortic valve
replacement (TAVR)
• has been developed for treatment of patients
with severe symptomatic AS
• who have an unacceptably high estimated
surgical risk
• due to technical issues with surgery (eg, a
porcelain aorta or prior mediastinal radiation,
prior pericardiectomy with dense adhesions
or prior sternal infection with complex
reconstruction, or a patent left internal
mammary graft lying beneath the sternum)
2012 American College of Cardiology
Foundation/American Association for Thoracic
Surgery
Calcific aortic valve stenosis with the following
echocardiographic criteria:
1. Severely calcified valve leaflets with
reduced systolic motion AND
2. Mean gradient >40 mm Hg or jet velocity
>4.0 m/s OR
3. Aortic valve area of <1.0 cm2 or indexed
effective orifice area <0.5 cm2/m2
Management strategy for patients with severe aortic stenosis.Preoperative coronary
angiography should be performed routinely as determined by age, symptoms, and coronary risk
factors.
2006 WRITING COMMITTEE MEMBERS et al. Circulation
2008;118:e523-e661Copyright © American Heart Association
THANK YOU!References:
1. John Hopkins Internal Medicine board
review
2. MKSAP 15
3. www.uptodate
4. ACC/AHA guideline 2008- 2006 WRITING
COMMITTEE MEMBERS et al. Circulation
2008;118:e523-e661