Cardiology>>>>>Valvular heart disease and Endocarditis
Question 8#

Past Medical History (An 82-year-old retired solicitor presents to the ED with chest pain radiating to his jaw. He has hypertension treated with ramipril 5 mg bd but is otherwise normally fit and well. His admission ECG shows atrial fibrillation with a ventricular rate of 90 bpm, LVH, and widespread ST segment depression. His peak troponin is 110 ng/L (normal <30 ng/L). He is started on treatment for an acute coronary syndrome and listed for an inpatient angiogram. You are asked to perform a bedside echocardiogram as a systolic murmur is heard on the post-take ward round. 

coronary angiogram showed:

• LMS: mild atheroma
• LAD: severe (90%) proximal stenosis; good distal target
• LCx: small vessel with diffuse distal atheroma
• RCA: dominant; moderate (50–60%) mid-vessel focal stenosis.)

Three years later, is admitted to hospital with chest pain. A repeat echocardiogram shows a heavily calcified aortic valve with a peak velocity of 4.8 m/s, valve area of 0.8 cm² , and moderately impaired LV systolic function. Two years ago he had a right upper lobe lung lobectomy with chemoradiotherapy for a localized primary bronchogenic carcinoma. Your consultant has asked you to write a referral letter to the ‘heart team’ at the regional tertiary centre to consider this patient for a transcatheter aortic valve implantation (TAVI).

Which one of the following is a contraindication for TAVI?

A. Plaques with mobile thrombi in the ascending aorta or arch
B. Porcelain aorta
C. Home oxygen therapy
D. Severe peripheral vascular disease
E. LVEF <30%

Correct Answer is A

Comment:

TAVI is recommended for patients with symptomatic severe AS who, according to the ‘heart team’, are unsuitable for conventional surgery because of severe comorbidity. Various factors need to be taken into account when making this assessment. A logistic Euro-SCORE of ≥20% has been suggested as an indication for TAVI therapy, but in patients with a lower Euro-SCORE other conditions such as a porcelain aorta, a history of chest radiation, and patent coronary bypass grafts make AVR less suitable. Specific contraindications for TAVI that are listed in following table: 

ESC Guidelines 2012: contraindications for transcather aortic valve implantatation (TAVI)