1.
Case presentation
Diana Girnita, MD, PhD
The Christ Hospital

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.
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.
PMHx
• CAD (coronary artery disease)
• Hypertension
• Hyperlipidemia
• Diabetes mellitus type II
• Depression with anxiety attacks
• Obesity

5.
Social History
• Married, 2 kids
• Farmer
• Never a smoker
• Alcohol: 2 beers/ night

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.
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.
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.
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.
EKG

11.
CXR
• Stable cardiomegaly.
• Mediastinal contours unremarkable.
• No pulmonary infiltrate or pleural
effusion.
• Pulmonary vessels within normal
limits.
IMPRESSION:
No acute disease

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.
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.
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.
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.
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.
Aortic stenosis-
management

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.
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.
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.
Classic symptoms
1. decreased exercise tolerance and
dyspnea on exertion (Heart failure)
2. Syncope or dizziness
3. Angina

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.
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.
Investigations
• ECG
• CXR
• Exercise testing
• Echocardiography
• Coronary angiography

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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Answer:
• Correct answer: B- in severe, symptomatic
aortic stenosis, AVR improves long-term
survival and quality of life.

37.
Effective treatments for severe AS.
1. Surgical replacement of
the aortic valve
2. Transcatheter aortic
valve replacement
(TAVR)

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.
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.
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.
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.
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.
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