You review a 59-year-old man with long-standing hypertension in clinic. He has no other comorbidities. He complains of some breathlessness, but this does not limit his physical activity. A transthoracic echocardiogram demonstrates aortic root dilatation and severe aortic regurgitation.
Which one of the following is not an indication for surgery?
This man’s echocardiogram shows a dilated aortic root. In this case the likely cause is his long-standing hypertension. In aortic root disease indication for surgery is based on the maximal aortic diameter, regardless of the severity of aortic regurgitation. Patients with Marfan’s syndrome should be offered surgery when their aortic root diameter is ≥45 mm; the figure is ≥50 mm for patients with a bicuspid aortic valve and ≥55 mm for any other patient (including those with aortic root dilatation secondary to hypertension, as in this case). Other indications for surgery in severe aortic regurgitation are:
You are asked to review the echocardiogram of a 74-year-old woman with a loud pansystolic murmur. (following pic)
The following statements are all true, except:
The video shows prolapse of the posterior mitral valve leaflet. There is eccentric MR.The vena contracta (VC) can be measured in both central and eccentric jets to estimate the severity of MR. The VC should ideally be measured in the apical four-chamber view. PISA is more accurate for central regurgitant jets. Systolic pulmonary vein flow reversal is specific for severe MR, but is not sensitive. Echocardiographic criteria for the definition of severe mitral regurgitation are shown in following Table:
ESC guidelines 2012
You are reviewing a 65-year-old farmer in the post-PCI clinic. He had primary angioplasty to his RCA for an inferior STEMI 3 months previously. He reports exertional breathlessness but no chest pain. His current medications are aspirin 75 mg od, clopidogrel 75 mg od, ramipril 5 mg bd, bisoprolol 5 mg od, and atorvastatin 80 mg od. On examination his BP is 110/70 mmHg and his heart rate is 60 bpm. You hear a soft pan-systolic murmur at his apex. His chest is clear and there is no pedal oedema. His ECG shows atrial fibrillation. He manages only 3 minutes on the treadmill with no chest pain or ECG changes, stopping due to breathlessness. You request an urgent echocardiogram, which demonstrates mild LV systolic dysfunction. The inferior wall is akinetic, there is some tethering of the posterior mitral valve leaflet, and as a result some mitral regurgitation (ERO = 0.2 cm2 ).
What is the next appropriate step in his management?
This patient has secondary MR. His recent infarct has led to alteration of his LV geometry (inferior akinesis) resulting in tethering of structurally normal MV leaflets. Ischaemic MR is a dynamic condition and its severity may vary depending upon changes in loading conditions. The ESC Guidelines published in 2012 propose that, because of their prognostic value, lower thresholds of severity using quantitative methods should be used in secondary MR. An ERO ≥20 mm2 or a regurgitant volume ≥30 mL/beat suggests severe MR. As ischaemic MR is a dynamic condition, stress testing may play a role in its evaluation. An exercise-induced increase in the ERO of ≥13 mm2 has been shown to be associated with a large increase in the relative risk of death and hospitalization for cardiac decompensation (ESC Guidelines 2012).
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. Calculate the aortic valve area (using the continuity equation) from the following pics
CSAAV = CSALVOT × VTILVOT/VTIAV
CSALVOT = 0.785(2.482)
CSAAV = 4.82 × 11.61/70.22
CSAAV = 0.798 cm2 = 0.8 cm2
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.
His coronary angiogram shows:
Which one of the following statements is correct?
This patient has severe symptomatic aortic stenosis and two moderate to severe coronary stenoses with good distal targets. As he has no other significant comorbidity, he should be referred for AVR and two-vessel CABG. PCI and TAVI should be considered only if the patient is judged to be unsuitable for AVR after surgical consultation. In patients with a primary indication for aortic/mitral valve surgery, CABG is recommended for coronary artery stenosis ≥70% and should be considered for coronary artery stenosis ≥50–70% (ESC Guidelines 2012). This patient’s operative mortality for AVR and CABG is likely to be at least 4.5%. Table 3.2 shows the estimated operative mortality after surgery for valvular heart disease. AF is an independent risk factor for poor outcome after cardiac surgery. The ESC Guidelines for the management of AF recommend that surgical ablation should be considered in patients with symptomatic AF and may be performed in patients with asymptomatic AF undergoing cardiac surgery if feasible with minimal risk.
ESC guidelines 2012: operative mortality after surgery for valvular heart disease:
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