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Chapter 47: Aortic Valve Disease

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A 65-year-old man was referred for cardiac consultation following a 2-year history of dyspnea on minimal exertion. He had a coronary angiography in the past that revealed normal coronaries. His physical examination revealed a 3/6 systolic ejection systolic murmur across the precordium. An echo was obtained showing left ventricular dysfunction with an EF of 38%, a calcified aortic valve with a mean gradient of 29 mm Hg, and AVA (aortic valve area) of 0.9 cm2. Which of the following is the best next step in the management of this patient?

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A. SAVR after coronary angiography

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B. Left and right cardiac catheterization

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C. Exercise treadmill testing

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D. TAVR

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E. Dobutamine stress echocardiography (DSE)

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The answer is E. (Hurst’s The Heart, 14th Edition, Chap. 47) There is a discrepancy between gradient and valve area calculation, and this needs to be sorted out before making any decision with regard to the interventions (options A and D are thus not correct). This patient may have low-flow/low-gradient severe AS with reduced EF. AS severity may be difficult to assess under resting conditions in low LVEF patients,1-5 and DSE (option E) can help clarify the issue by allowing reassessment of the AVA at a higher flow. With normalized flow, a patient with true severe AS increases the mean transaortic gradient in tandem with valve flow so that AVA remains nearly constant. A patient with pseudo-severe AS, a condition where low flow causes an overestimation of AS severity, increases valve flow with little increase in gradient, resulting in increased AVA. Options B and C would not be useful in resolving the discrepancy between gradient and valve area calculation in this case.

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A 67-year-old man with a prior medical history of hypertension and atrial fibrillation was referred for cardiac consultation following a 2-year history of chest discomfort on minimal exertion. His physical examination revealed a late peaking 3/6 ejection systolic murmur with a soft and single S2. An echo was obtained showing left ventricular hypertrophy with an EF of 62%, moderate right ventricular dysfunction, moderate mitral regurgitation, a calcified aortic valve with a mean gradient of 29 mm Hg, and AVA of 0.7 cm2. Which of the following parameters may not be a contributor to paradoxical low-flow, low-gradient severe aortic stenosis?

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A. Hypertensive heart disease

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B. Atrial fibrillation

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C. Right ventricular dysfunction

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D. Occult aortic regurgitation

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E. Mitral regurgitation

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