A 77-year-old patient is admitted to the hospital for urosepsis. His past medical history is significant only for having undergone AVR 5 years prior. On examination, he is febrile to 102°F. Heart rate is 106 bpm. Carotid upstrokes are full. Chest examination reveals clear lung fields. Cardiac examination reveals a hyperdynamic apical impulse, which is not displaced. S1 and S2 are normal. An early-peaking systolic murmur is heard at the sternal border. No diastolic murmur is heard. An echocardiogram is performed. Peak/mean gradients are 50/30 mmHg. LVOT VTI (velocity time integral) is 36 cm and aortic valve VTI is 78 cm. The aortic valve itself is not well seen. Flow in the descending thoracic aorta is normal. An echocardiogram 2 years prior had revealed peak/mean gradients of 24/12 mmHg. LVOT VTI was 19 cm and aortic valve VTI 41 cm.
The patient remains febrile despite 1 week of antibiotic therapy. Electrocardiogram reveals a new long first-degree atrioventricular (AV) block. The patient becomes progressively dyspneic. A short, regurgitant murmur is heard.
What do you recommend?
TEE with surgical consultation. The clinical scenario, with a new firstdegree AV block and acute aortic regurgitation, is highly suspicious for prosthetic valve abscess and possibly even partial dehiscence. A transesophageal echocardiogram should be performed, but prompt surgical consultation should also be requested given the high suspicion for aortic root abscess and the onset of heart failure symptoms.
A 56-year-old man with mitral stenosis presents for evaluation. He has NYHA class II-III shortness of breath.
Physical Examination:
He undergoes percutaneous valvuloplasty. The following morning, on examination, you note that he is comfortable. His oxygen saturation is 100% on room air. Opening snap is 0.12 milliseconds after S2. A shorter decrescendo diastolic rumble is heard. You obtain a predischarge echocardiogram. The report indicates a pressure half-time of 180 milliseconds.
What do you do next based on the echocardiogram?
Repeat echocardiogram with planimetry of mitral valve area. With acute changes in atrial and ventricular compliance (as with valvuloplasty), the half-time is unreliable. Usually 72 hours or more is required after the procedure before the half-time can be used with reasonable reliability. Planimetry, if performed correctly, would provide a more reliable estimate of stenosis severity. Clinically, the patient seems to have had a good result (longer S2–OS interval, shorter murmur). TEE rarely provides incremental data on mitral stenosis if the transthoracic images are reasonable.
The echocardiogram reveals a small left-to-right shunt at the atrial level by color.
Observation. The shunt is secondary to the valvuloplasty procedure where the interventionalist must perform an interatrial septal puncture in order to access the mitral valve. Most of these small shunts will close over the next 6 months without any intervention. The shunt is left to right by color. He has good O2 saturation on room air, making any significant right-to-left shunting unlikely. Anticoagulation with an atrial septal defect/patent foramen ovale may be recommended in certain settings, however not indefinitely, given the good chance that the defect will close.
An 80-year-old man underwent successful AVR with a bioprosthetic valve 4 months ago. He presents to your office for a routine follow-up visit. He is asymptomatic. He is in sinus rhythm. Echocardiogram reveals a normally functioning prosthetic valve. Chamber dimensions are normal with normal biventricular function. He has no clinical history of embolic events.
Which of the following should you recommend?
Antibiotic prophylaxis, with yearly office visits. He requires antibiotic prophylaxis with a prosthetic valve (by 2007 guidelines, prosthetic cardiac valves are an indication for subacute bacterial endocarditis prophylaxis prior to dental procedures). These patients still require close follow-up with complete evaluation on a yearly basis. Some advocate a 3-month period of warfarin therapy after bioprosthetic valve placement. He is now 4 months out, and has no other indications or a high-risk profile (LV dysfunction, prior embolic event, and atrial fibrillation); thus warfarin is no longer needed at this time. Similarly, there is no specific indication in this man for clopidogrel therapy.
A 28-year-old 20-week pregnant woman is referred to your clinic after being diagnosed with mitral valve prolapse and severe MR on an echocardiogram ordered by her obstetrician. She reports no symptoms prior to pregnancy but since being told her diagnosis is extremely worried and has noticed some shortness of breath on exertion (New York Heart Association [NYHA] class II). She is clinically euvolemic.
No therapy at present but follow carefully with serial clinical and echo evaluation. Antibiotics are not recommended routinely for prophylaxis at the time of delivery for patients with valvular heart disease unless infection is suspected. If there is evidence of pulmonary congestion treatment with diuretics and afterload reduction with hydralazine is recommended but ACEIs are teratogenic and are absolutely contraindicated in pregnancy. Your patient is clinically euvolemic and therefore medical therapy need not be initiated. Surgery should only be performed if the mother’s life is threatened due to the associated high fetal mortality rate (20% to 30%). Management will involve close follow-up and monitoring by her cardiologist and obstetrician and treatment only if her clinical situation deteriorates.
Click to expand