A 68-year-old man is referred for assessment of an ejection systolic murmur after presenting with worsening breathlessness. Image loops taken from his transthoracic echocardiogram are shown
The following measurements were obtained during transthoracic echo:
Coronary angiography demonstrated mild atheroma without any significant disease.
Which one of the following would be the most useful next investigation?
This patient has a small aortic valve area and a modest peak gradient in the context of LV impairment (low flow, low gradient AS). In this subset of individuals low-dose dobutamine stress echocardiography can help to distinguish truly severe AS from pseudo-severe AS.
A 79-year-old retired farmer with known aortic stenosis (AS) returns for his annual surveillance echocardiogram. He remains physically active with no symptoms. His BP is 180/110 mmHg.
The following summary is obtained:
Which one of the following statements is correct?
There is no good evidence from randomized controlled trials that statins affect the progression of AS. Exercise testing is contraindicated in symptomatic patients with AS but is recommended in physically active patients for unmasking symptoms and in the risk stratification of asymptomatic patients with severe AS. The development of symptoms or a fall in blood pressure is a predictor of symptom development/poor outcome and therefore is an indication for surgery (ESC Guidelines 2012). In addition, the guidelines recommend that if patients are not physically active or exercise testing is negative, surgery should or may be considered in the presence of specific risk factors and low/intermediate individual surgical risk. Risk factors for consideration of aortic valve surgery are shown in following box:
A BNP level of 120 pg/mL is only mildly elevated and may be due to other causes. A very raised BNP level is defined as >400 pg/mL.
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:
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?
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)
The Doppler profile shown below is taken from a patient presenting with breathlessness.
What is this Doppler profile least likely to be compatible with?
The E:A ratio is >2 with a deceleration time of <150 ms in keeping with severe diastolic dysfunction. Assessment of the severity of mitral stenosis using pressure half-time (PHT) should be performed with continuous-wave (CW) Doppler. The PHT in severe MR is long (>220 ms). The mitral valve area can be calculated using the formula MVA = 220/PHT. Although the Doppler trace shown in question is a pulsed wave (PW) of LV inflow. It would be unusual to obtain this pattern in severe MS.
You are asked to review an echocardiogram of a 82-year-old woman who has both severe aortic stenosis (AS) and severe mitral regurgitation (MR). All the following statements are true in patients with combined or multiple valve lesions except:
AR shortens the PHT in mitral stenosis. PHT is a measure of the change in pressure between two cardiac chambers. In significant AR, there is likely to be high LV end-diastolic pressures. This leads to a higher pressure difference between the LV and LA—hence shortening of the PHT in MS. This underestimates the severity of MS. Associated MR leads to underestimation of the severity of AS since decreased stroke volume due to MR lowers the flow (and gradient) across the AV. Similarly, severe AS causes high ventricular pressures leading to overestimation of coexistent MR In mixed aortic valve disease, the presence of significant AR will lead to increased stroke volume and hence flow (and gradient) across the aortic valve. Therefore AR can overestimate the severity of AS. Methods that are less dependent on loading conditions, such as planimetry of valve area, should be utilized.
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