A 78 year old female, diabetic, overweight and hypertensive presented with severe shortness of breath, orthopnea and paroxysmal nocturnal dyspnea

A 78 year old female, diabetic, overweight and hypertensive presented with severe shortness of breath, orthopnea and paroxysmal nocturnal dyspnea. She has limited mobility at home due to easy fatigue. On examination she was restless , tachycardiac with heart rate of 130 beats per minute, respiratory rate of 26 per minute and Blood Pressure of 110/60 mmHg. Auscultation revealed ejection systolic murmur at upper sternal border radiating to neck, S₃gallop and a displaced PMI on palpation. There were bilateral crackles in the chest. ECG showed ST depression in anterior precordial leads. Labs revealed a Troponin of 170, Creatinine of 2.0 mg/dl and BNP of 1617. Chest X-Ray revealed pulmonary edema. Echocardiography revealed EF of 35%, global hypokinesia, Aortic Valve Area of 0.8cm²and a mean gradient of 28 mmHg.

a) What are the treatment options available and which would you recommend for her?

b) Name recent trial conducted for such intermediate to high risk patients and its result interpretation?

c) What is the reason for low gradient, despite critical aortic stenosis?

d) What is the complication of TAVR?

Answers:

a.      Open surgical repair and TAVR, in this patient TAVR is recommended as he is at high surgical risk due to multiple comorbid conditions.

b.      SURTAVI Trial

c.       Paradoxical low-flow (PLF) aortic stenosis – LV dysfunction secondary to increased afterload imposed by critical aortic stenosis

d.      Complications:

Bleeding
Hematoma
Stroke
CHB requiring PPM insertion
Para-valvular leakObstruction of coronary ostea

References:

Chapter 15, page 238 – Aortic valve disease - Manual of Cardiovascular Medicine Fourth Edition - Brian P. Griffin MD FACC
Reardon MJ, et al. "Surgical or transcatheter aortic-valve replacement in intermediate-risk patients". The New England Journal of Medicine. 2017. epub 2017-03-17:1-11.[PubMed]

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𝘼𝙣𝙩𝙞𝙘𝙤𝙖𝙜𝙪𝙡𝙖𝙩𝙞𝙤𝙣 𝘼𝙛𝙩𝙚𝙧 𝙎𝙩𝙧𝙤𝙠𝙚 in Patient with AF and acute IS/TIA European Heart Association Guideline recommends: • 1 days after TIA • 3 days after mild stroke • 6 days after moderate stroke • 12 days after severe stroke Early anticoagulation can decrease a risk of recurrent stroke and embolic events but may increase a risk of secondary hemorrhagic transformation of brain infarcts. The 1-3-6-12-day rule is a known consensus with graded increase in delay of anticoagulation between 1 and 12 days after onset of ischemic stroke or transient ischemic attack(TIA), according to neurological severity based on European expert opinions. However, this rule might be somewhat later than currently used in a real-world practical setting.

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