Pathology case presentation - Severe Aortic Stenosis with Ischemic Heart Disease. (Management of TAVI)

1. Pathology Case
Presentation
Name : Yukta S. Wankhede
PRN : 21040143006
Programme : M.Sc Medical Technology
(Cardiac Care Technology)
Subject : Pathology Case Presentation II

2. A 65-year-old female presents with symptoms of shortness of breath, fatigue, sweating,
pedal edema, pounding in the chest, chest pain, exertion while taking stairs, intermittent
claudication, and bluish coloration of the skin. The patient has a history of Hypertension
,a mild heart attack at age 55 and asymptomatic aortic stenosis.
CASE

3. Name : XYZ
Age : 65yrs
Gender : Female
UHID no. SUHRC 145678
Consultant Name : Dr. ABC
Patient Details

4. Current History / Present Complications
Shortness of Breath
Fatigue
Sweating
Pedal edema
Pounding in chest
Chest pain
Exertion while taking stairs
Intermittent claudication
Bluish coloration of skin.
History

5. Past History
Hypertensive
IHD since 10yrs
Medication History
Perindopril 5mg OD (Anti-hypertensive)
Atorvastatin 40mg OD (Statin Medication)
Histor
y

6. Family History
Mother has a history of Diabetes Mellitus and hypertension.
Generation history of IHD.
Personal History
Mild heart attack at age of 55yrs
Angiography showed mild luminal irregularities.
Asymptomatic Aortic Stenosis (denied SAVR due to being considered
high surgical risk.)
History

7. Occupational History
Retired Professor
Menstrual History
On Menopause since approx. 20yrs.
History

8. Vitals
General Examination
General Investigation
Systemic Examination
Clinical Examination

9. Clinical Examination: Vitals
Vitals Patient's Range Normal Range
Temperature (degree C) 36.3◦ C 36 - 37
Pulse Rate ( Beats per minute ) 85 bpm 60 - 100
Respiratory Rate (Breaths per
minute)
19/min 16 - 20
O2 Saturation 90% greater than 97%
Blood Pressure (mmHg) 110/80 mmHg 120/180

10. General Examination
Height: 150cm
Weight : 80kg
BMI:35.6 (Obesity)
Clinical Examination: General Examination

11. General Investigation
Pallor - Present
Icterus - Absent
Cyanosis - Present
Clubbing -Present
Lymphnopathy - Absent
Edema- Present
Clinical Examination: General Investigation

12. Inspection :
Posture - Normal
Symmetry of the thorax - Normal
Color of Skin - Pallor
Deformity of skin - No
Breathing Pattern - Fast Cyanosis
PeripheralCyanosis Eyes:Arcus
Senilis
Clinical Examination: Systemic Examination

13. Clinical Examination: Systemic Examination
Inspection :
Breathing Pattern - Grade 2(Moderate)
MRC Dyspnoea Scale

14. Palpation :
Examination extremitiesties for
edema.
Note the puffiness of frame edema by
the scalecalled Pitting Edema Scale.
Pitting EdemaScale- 3+
Clinical Examination: Systemic Examination

15. Palpation :
Slow rising peripheral pulseassociatedwith adelayed sustained peak.
Bounding Pulse- 4+grade
Radiating to the carotid arteries
Clinical Examination: Systemic Examination

16. Percussion :
Normal
Auscultation :
A grade 4/6 crescendo–decrescendo.
Mid-systolic ejection murmur heard best at the right upper sternal
border radiating to the neck and carotid arteries.
No diastolic murmur was heard.
The apex beat was slightly displaced laterally at the left side.
Lung auscultation was clear, and jugular vein distension was not
observed.
Clinical Examination: Systemic Examination

17. Cardiovascular System
Apical Pulse
Third Heart Sound
Cardiac Murmur
Tachycardia
Increased JVD
Renal System
Decrease in urine output
Clinical Examination: Systemic Examination
Respiratory System
Dyspnea (NYHA - IIGrade)
Paroxysmal Nocturnal
Dyspnea
Cough on exertion
Central Nervous System
Confusion
Light headiness
Headache

18. Congestive Heart Failure
Valvular Heart Disease
Cor-Pulmonale
COPD
Acute Kidney Failure
Differential Diagnosis

19. Congestive Heart Failure
Valvular Heart Disease
Provisional Diagnosis

20. CBC and Lab Investigation
Investigation
Lab Patient’s Range Normal Ranges
WBC (10^9/L) 6 4 - 10
RBC (10^12/L) 4.5 4.5 - 5.5
Hb g/dl 14.7 12 - 16
Albumin 2.5 3.5 - 5.2
K 3.7 3.5 - 5.3
Na 140 135 - 153
Mg (mg/dl) 1.4 1.6 - 2.6

21. Investigation: CBC and Lab Investigation
Lab Patient’s Ranges Normal Ranges
CK (mg/dL) 1.2 6-1.1
Troponin (ng/ml) 0.2 below 0.04
AST (IU/L) 36 10-40
INR 1 1.1 or below
HbA1c 5 below 5.7

22. 6 min walk test
By The Brog Scale -
Result in range 1 Very
Light Activity.
Investigation

23. Investigation: Non-Invasive
ECG
Left Ventricular
Hypertrophy in R
wave - V5 and S
wave in V1 .
ST elevation in
V1, V2 and V3.
ST depression in
V4 , V5 and V6.

24. Investigation: Non-Invasive
ECHO
(A) Parasternal Long Axis view &
(B) Parasternal Short Axis view at
Aortic valve level: a heavily calcified
and rigid aortic valve with severe
aortic stenosis.
Ejection Fraction : 35%

25. Investigation: Non-Invasive
Calculated aortic valve area
Maximal velocity
Elevated peak gradients
Mean pressure gradients
LV end-diastolic dimensions
LV end-systolic dimensions
LV end ejection fraction
0.4 cm2/m2
5.6 m/s
124 mmHg
7 mmHg
50 mm
36 mm
67%
ECHO
Continuous wave Doppler technique revealed
Moderate AR was identified
No LV wall motion abnormality
The thickness of the septum and LV posterior wall was
14 mm.

26. Investigation: Non-Invasive
ECHO
Transesophageal echocardiography
(TEE) revealed an eccentric aortic
valve orifice during systole with
severe stenosis.
Real-time TEE three-dimensional
(3D) echocardiography revealed an
eccentric opening in an aortic valve
and a lateral attachment to the aorta
at the orifice level, which are
consistent with the findings of
unicommissural UAVs.

27. Chest X-ray
The Chest X-Ray
demonstrated a prominent
right mediastinal border
occupied by the ascending
aorta.
There was an enlarged aortic
knob.
Cardiothoracic Ratio: 46%
Absence of pleural effusion,
with slight pulmonary
congestion.
Investigation: Invasive

28. Cardiac
Catheterization
Left Anterior
Descending Artery:
Middle LAD stenosis
and LAD diagonal
stenosis.
Right Coronary
Artery: Proximal
20% Stenosis.
Investigation: Invasive

29. Severe Aortic Stenosis with Ischemic Heart Disease.
Final Diagnosis

30. Pathophysiology
Severe Aortic Stenosis with Ischemic Heart Disease.

31. Management

32. First Day:
The patient was admitted to the hospital emergently.
Presents with symptoms of shortness of breath, fatigue, sweating, pedal edema,
pounding in the chest, chest pain, exertion while taking stairs, intermittent
claudication, and bluish coloration of the skin. The patient has a history of
Hypertension , a mild heart attack at age 55 and asymptomatic aortic stenosis.
Management

33. Preoperative Evaluation for TAVI
Patient's pre-operative risk assessment for 30-day mortality—the Society of
Thoracic Surgeons (STS) score—was elevated at 14.4%, and she was thus evaluated
for TAVI. Multiple tests were performed to assess the feasibility of the procedure.
CT angiograms of the thorax, abdomen, and pelvis were implemented to
investigate for abnormalities of the vasculature that would prohibit a transfemoral
approach for TAVI.
Considering that stroke is a common complication of this procedure, a carotid
ultrasound was performed to evaluate for carotid atherosclerosis.
Two cardiothoracic surgeons examined the patient and declared that she would be
at high mortality risk to have SAVR, and thus they recommended TAVI.
Management

34. Performance of TAVI
Under general anesthesia, the right and left femoral arteries were each accessed with 6-french
sheaths. A temporary pacemaker was placed in the right ventricle through an 8-french sheath in the
right femoral vein.
Balloon valvuloplasty was performed by advancing a balloon via the right femoral artery sheath, and
during rapid ventricular pacing at 160 beats per minute, inflating it across the aortic valve to clear the
stenosis and deploy the 26-mm SAPIEN S3 bioprosthetic aortic valve, which expanded within the
native aortic valve.
The purpose of rapid ventricular pacing during TAVI is to reduce cardiac output, which facilitates
balloon inflation across the valve and placement of the bioprosthetic aortic valve.
The mean valvular gradient after TAVI decreased to 1.9 mm Hg (normal is <5 mm Hg). There were
no intraoperative complications. The patient was extubated and transferred to the coronary care unit
with the temporary transvenous pacemaker, which was removed two days later.
Management

35. Management
Figure 1. Balloon inflation across the aortic valve
Figure 2. Expanded SAPIEN S3 valve within the native aortic valve.

36. Postoperative Course
A 2D echocardiogram performed on the first postoperative day showed that the prosthetic
aortic valve was well seated without any regurgitation.
A 12-lead electrocardiogram revealed new-onset paroxysmal atrial fibrillation with the
slow ventricular response (her heart rate was in the range of 50 beats per minute).
Anticoagulation treatment for the prevention of thromboembolic events was initiated with
Apixaban 2.5 mg BID.
In addition, Clopidogrel 75 mg daily was started to prevent stenosis of the bioprosthetic
valve.
The patient was discharged home three days post procedure.
Management

37. Follow-up Visits
One month later, during a follow-up appointment with the primary care provider, the
patient was found to be severely bradycardic and became unresponsive for a few minutes.
She regained consciousness without any resuscitative efforts and was taken emergently to
the hospital. An inpatient limited 2D echocardiogram showed normal systolic function
with an ejection fraction of 55–60%.
Nothing was reported on the function of the bioprosthetic aortic valve. The patient
remained asymptomatic during the hospitalization and was discharged home the next day.
A review of the patient’s home medications revealed that she was taking the negative
chronotropic medication metoprolol succinate, which may have precipitated his syncopal
episode.
She was instructed to stop this medication.
Management

38. Follow-up Visits
During the six-month follow-up visit, the patient reported continued symptomatic
improvement.
She had mild peripheral edema. Dyspnea occurred with more significant exertion; thus,
NYHA functional class II. He remained off metoprolol as instructed, and despite being
bradycardic with a heart rate of 55 beats per minute, she did not experience any further
episodes of dizziness.
2D echocardiogram revealed that the bioprosthetic valve was well seated without any
paravalvular leak. The ejection fraction was 65% and he had mild diastolic dysfunction.
The patient was told to stop clopidogrel (as she had completed the standard six-month
treatment), and to continue antiplatelet therapy with Aspirin 81 mg daily indefinitely.
Management

39. Thank You