PATIENT CASE: AORTIC STENOSIS
Mrs. R is a 92-year-old woman with history of severe aortic stenosis (AS), hypertension (HTN), atrial flutter, and nonobstructive coronary artery disease (CAD). She first developed symptoms around 2 years ago that were characterized by mild dyspnea on exertion and fatigue, and was appropriately referred for further therapy with either a surgical or transcatheter aortic valve replacement (TAVR). However, the patient at the time refused any further intervention for fear of complications given her advanced age.
She returned to the clinic 2 years later with now severe dyspnea even on minimal exertion, significant fatigue, dizziness, lower extremity edema, and weight loss. Physical examination revealed a frail elderly woman. The carotid pulse was slow and decreased in amplitude. On cardiac auscultation a soft S2 was heard along with a late-peaking systolic murmur that was best heard at the right upper sternal border and radiated to the carotids.
Repeat echocardiography revealed a heavily calcified aortic valve with limited mobility (Figure 15-1). Doppler assessment of the aortic valve yielded a peak velocity of 5.4 m/sec, a mean gradient of 62 mm Hg, and a calculated aortic area of 0.6 cm2, making the diagnosis of critical AS (Figure 15-2). The left ventricle (LV) showed moderate concentric hypertrophy with preserved ejection fraction (EF), but with evidence of diastolic dysfunction. Because of her significant, activity-limiting symptoms, the patient agreed to undergo further therapy. She was deemed high surgical risk because of high frailty score. She was therefore, referred for transcatheter aortic implantation with an Edwards SAPIEN 3 prosthesis. The procedure was successfully completed. However, the patient experienced a prolonged hospital course because of her advanced disease, significantly delayed intervention since symptom onset, and frailty. She has since recovered with markedly improved symptoms, and the latest echocardiogram shows a normally functioning prosthetic valve with a peak velocity to 2.8 m/sec, and mean gradient of 16 mm Hg (Figure 15-3).
Parasternal long-axis echocardiographic view of a patient with severe aortic stenosis due to calcific degenerative disease. Note the heavily calcified aortic valve and the concentric hypertrophy of the left ventricle. Abbreviations: AV, aortic valve; LA, left atrium; LV, left ventricle.
Transthoracic echocardiographic assessment of a stenotic aortic valve. Panels A and B (parasternal long-axis view and parasternal short-axis view) show the heavily calcified aortic valve with restricted opening in systole. Doppler hemodynamic assessment of the aortic valve (panels C and D) show significantly elevated velocity at 5.4 m/sec, mean pressure gradient of 62 mm Hg, and a calculated aortic valve of 0.6 cm2. A diagnosis of critical aortic stenosis is made. Abbreviations: AV, aortic valve; LA, left atrium; LV, left ventricle.