An 80-year-old man presents to your office with complaints of chest tightness when climbing up a flight of stairs. His past medical history is unremarkable. On physical examination, he is in no acute distress. BP is 140/80 mmHg; pulse is 78 bpm and regular. Chest is clear. Carotid upstrokes are diminished. The PMI is sustained, but not displaced. A fourth heart sound is present. The second heart sound is diminished and single. A loud late-peaking systolic murmur is heard, loudest at the second intercostal space, radiating to the neck.
The patient is found to have an aortic valve area of 0.7 cm2 with a mean gradient of 60 mmHg. Following catheterization, he develops massive upper gastrointestinal bleeding. Endoscopy reveals a gastric ulcer with a bleeding vessel at its base. Cauterization is performed, which temporarily stops the bleeding. However, the bleeding recurs and urgent partial gastrectomy is recommended. He complains of chest pain during these bleeding episodes.
What is the best course of action?
Refer for percutaneous balloon valvuloplasty, followed by gastrectomy. He has symptomatic critical AS. AVR, with concomitant need for anticoagulation while on cardiopulmonary bypass, is not an attractive first option. Proceeding directly to gastric surgery would carry high risk, given the ongoing symptoms. Valvuloplasty would be a reasonable bridge to lower risk from the noncardiac surgery.
What valve would you recommend to an 80-year-old patient with severe symptomatic AS?
Bovine pericardial valve. He is at an age where there is substantial durability of the bioprosthetic valve. He is at increased risk for anticoagulation; thus, mechanical valves would not be the valve of first choice. By history, he would not appear to need anticoagulation for any other indication. Homograft is not unreasonable, but there would not appear to be any hemodynamic or durability benefits for an 80-year-old patient, and its insertion requires a more difficult operation.
A 28-year-old man presents for evaluation of difficult to control hypertension. He initially denies any symptoms but on further questioning admits to some leg fatigue and weakness and cold feet. On examination his BP is 180/90 mmHg, heart rate is 77 bpm and regular. His radial pulses are easily palpable but his femoral pulses are weak and there is radiofemoral delay. An ejection systolic murmur is heard at the left upper sternal border that radiates to the intrascapular region. In addition, there is a soft continuous murmur heard throughout the precordium.
Based on your suspicion you order a CT aorta (Fig. below).
What is the most common associated lesion?
∼50% of cases have a bicuspid aortic valve. Coarctation of the aorta is suspected clinically and confirmed on a gated CT angiogram of the thoracic aorta. This lesion is frequently associated with concomitant congenital cardiac anomalies, the most frequent of which is a bicuspid aortic valve (occurs in ∼50% to 85% of cases).
A 65-year-old man with a history of rheumatoid arthritis (well controlled) presents for evaluation of a heart murmur. He notes some increase in fatigue and decrease in activity level over the past 2 years, but denies any specific complaints of dyspnea. He leads a rather sedentary lifestyle. On examination, he is 6-ft, 1-in. tall. BP is 150/50 mmHg. Heart rate is 80 bpm and regular. Carotid upstrokes are brisk with a rapid upstroke and decline. Apical impulse is displaced and hyperdynamic. S1 and S2 are normal. A decrescendo, nearly holodiastolic murmur is heard along the left sternal border, loudest with the patient sitting up. An echocardiogram is performed, which reveals a dilated LV (end-diastolic dimension of 6.8 cm and end-systolic dimension of 3.5 cm). Ejection fraction is 55%. There is significant aortic regurgitation.
What do you most likely recommend?
Stress test. The patient has significant aortic regurgitation with a dilated LV although not yet at the dimension that would be an indication for surgery in the absence of symptoms (his end-systolic dimension is <5.0 cm and enddiastolic dimension is <7.0 cm). He leads a sedentary lifestyle, and although he has no dyspnea, he does relate some equivocal symptom. A stress test would be useful to assess functional capacity and to objectively assess symptoms. If he were to develop symptoms at a low level of exercise, this may be an indication for surgical intervention. A vasodilator may be useful (class IIb indication with dilated LV), but he would need more frequent follow-up, given the LV dilation.
4. He is started on a vasodilator and is seen back in 6 months. He reports no change in symptoms. A repeat echocardiogram demonstrates an enddiastolic dimension of 7.6 cm. Ejection fraction remains normal.
What do you recommend now?
Surgical intervention. (Refer for surgery.) His ventricle has dilated even further. An end-diastolic dimension of >7.5 cm is a class IIa indication for surgery and is associated with an increased risk of sudden death, even in the absence of symptoms.
Click to expand