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Aortic stenosis - case report

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A case about Aortic stenosis
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Aortic stenosis - case report

  1. 1. Case presentation Diana Girnita, MD, PhD The Christ Hospital
  2. 2. 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.
  3. 3. 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
  4. 4. PMHx • CAD (coronary artery disease) • Hypertension • Hyperlipidemia • Diabetes mellitus type II • Depression with anxiety attacks • Obesity
  5. 5. Social History • Married, 2 kids • Farmer • Never a smoker • Alcohol: 2 beers/ night
  6. 6. 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.
  7. 7. 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%
  8. 8. 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
  9. 9. 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
  10. 10. EKG
  11. 11. CXR • Stable cardiomegaly. • Mediastinal contours unremarkable. • No pulmonary infiltrate or pleural effusion. • Pulmonary vessels within normal limits. IMPRESSION: No acute disease
  12. 12. 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.
  13. 13. 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
  14. 14. 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
  15. 15. Peak gradient (mm Hg) Mean gradient (mm Hg) Valve area (thermodilution) (cm2) Valve area (Fick) (cm2) Aortic valve 51 39 1.04 0.99
  16. 16. 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
  17. 17. Aortic stenosis- management
  18. 18. 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
  19. 19. 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
  20. 20. Pathophysiology • Ao valve sclerosis: no significant gradient (Ao jet velocity ≤2.5 m/sec) • Aortic stenosis - antegrade velocity across an abnormal valve is at least 2.6 m/sec. • When AS becomes hemodynamically significant, 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
  21. 21. Classic symptoms 1. decreased exercise tolerance and dyspnea on exertion (Heart failure) 2. Syncope or dizziness 3. Angina
  22. 22. 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).
  23. 23. 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.
  24. 24. Investigations • ECG • CXR • Exercise testing • Echocardiography • Coronary angiography
  25. 25. AS severity Severity Mean gradient, mm Hg Aortic valve area, cm2 Mild <25 >1.5 Moderate 25-40 1.0-1.5 Severe >40 <1.0 Critical >80 <0.7
  26. 26. 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
  27. 27. 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.
  28. 28. 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%)
  29. 29. 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
  30. 30. Answer Answer: D Coronary angiography- This patient needs an AVR. He should have a preoperative cardiac catheterization to determine the need for concomitant CABG.
  31. 31. 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
  32. 32. 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)
  33. 33. 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.
  34. 34. 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.
  35. 35. 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
  36. 36. Answer: • Correct answer: B- in severe, symptomatic aortic stenosis, AVR improves long-term survival and quality of life.
  37. 37. Effective treatments for severe AS. 1. Surgical replacement of the aortic valve 2. Transcatheter aortic valve replacement (TAVR)
  38. 38. 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)
  39. 39. 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
  40. 40. 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)
  41. 41. 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
  42. 42. 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
  43. 43. 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