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