A 40 years old female presented with chest pain and light headedness on exertion

A 40 years old female presented with chest pain and light headedness on exertion. Examination showed B.P of 110/90 mmHg, delayed carotid upstroke, double apical impulse, Ejection Systolic Murmur radiating to carotid. ECG is remarkable for Left Ventricular Hypertrophy. Echocardiography revealed critical aortic stenosis with Aortic Valve Area of < 1cm², Mean Gradient of 30 mmHg and Left Ventricular Ejection Fraction of 60 %.

 

a) How would you differentiate between valvular and sub-valvular aortic stenosis?

b) What are the indications for cardiac catheterization and how will you calculate Aortic Valve Area?

c) What is paradoxical low flow severe Aortic Stenosis and give two reasons for it?

d) What are the class I indications of Aortic Valve Replacement?

e) What is the most likely reason for severe Aortic Stenosis in this woman?

Answers:

a.      Clinical findings of valvular aortic stenosis are presence of ejection click and soft A2. In subvalvular AS there is early diastolic murmur of AR, Heart size is larger,  No ejection click or post stenotic dilatation of aorta.

b.      To further evaluate the severity of AS when the clinical and echocardiographic findings diverge (ACC/AHA Class I Indication), Area calculated by Gorlin Equation.

c.       Paradoxical low-flow (PLF) aortic stenosis is defined by a stroke volume index <35 ml/m² despite the presence of preserved LV ejection fraction (≥50 %). This entity is typically characterized by pronounced LV concentric remodeling with small LV cavity, impaired LV filling, increased arterial load, and reduced LV longitudinal shortening.

d.      1) symptomatic severe AS, 2) asymptomatic patients with severe AS undergoing coronary artery bypass graft surgery, surgery of the ascending aorta, or surgery of another valve, 3) asymptomatic severe AS with a left ventricular ejection fraction less than 50%, and 4) asymptomatic severe AS with an abnormal exercise test showing symptoms on exercise clearly related to AS

e.      Paradoxical low gradient aortic stenosis

Reference:

1.      Chapter 15, page 246 – Valvular Heart Disease  - Manual of Cardiovascular Medicine Fourth Edition - Brian P. Griffin MD FACC

2.      Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC); European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, Alfieri O, Andreotti F, Antunes MJ, et al. (2012) Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 33: 2451-2496.