Board Review

1
Board Review

• Vikram Chhokar MD
• University of Tennessee
• Division of Cardiology

2
Question

• An 80-year-old Asian woman awakens at 2 a.m.
  feeling as if she were being smothered. She is
  brought to the ED and is found to be in pulmonary
  edema. She has a history of a heart murmur,
  discovered 20 years before. Prior to this episode
  she says she was in good health, although she has
  not been physically active due to arthritic
  discomfort for the past 5 years. On careful
  questioning she admits to brief episodes of
  pressure-like sensation in her chest especially
  when she becomes aggravated.

3
Question

• Physical examination BP 150/110 mmHg, pulse
  120/min, respirations 24/min. Neck veins 10cm.
  Lungs have rales 3/4 the way up posteriorly
  bilaterally. Carotids are difficult to feel. PMI
  is in the 5th intercostal space just outside the
  midclavicular line and sustained. There is a
  grade II/VI systolic ejection murmur at the base
  and a grade II/VI diastolic blowing murmur at the
  3rd left intercostal space. There is an S4 and an
  S3 gallop. There is no hepatomegaly and no pedal
  edema.

4
Question

• Laboratory Chest X-ray slightly enlarged
  cardiac silhouette, pulmonary vascular
  redistribution and pulmonary edema. ECG QS in
  V1, a small r in V2, a 25mm R wave in V5 and a
  30mm R wave in V6. There is 2mm ST-segment
  depression in V4-6 . Echo estimated EF 55,
  first troponin lt0.3 ng/ml.
• The patient is given O2, Lasix, digoxin, and
  enalapril and becomes less dyspneic. Her pulse
  decreases to 90/min and BP to 110/85 mmHg.

5
Question

• The most probable diagnosis in this case is
• A. Severe AR
• B Severe aortic stenosis
• C. Hypertensive cardiovascular disease.
• D. Acute non-ST-elevation myocardial infarction.
   
• E. Congestive heart failure with diastolic
  dysfunction.

6
Answer

• The correct answer is B.The pulses and BP are
  against severe aortic regurgitation. Although the
  patient probably has angina, and even may have
  coronary artery disease, the presence of the
  systolic murmur, the poor arterial pulses, the
  severe LVH on ECG make aortic stenosis the likely
  diagnosis. Although the BP was elevated when she
  was in severe failure due to the excessive
  sympathetic stimulation and activated renin
  angiotensin system, when the patient was treated
  the BP returned to normal, inconsistent with
  acute heart failure due to hypertensive disease.

7
Aortic Stenosis

• Etiology based on location
• Supravalvular
• Subvalvular-
• Valvular

8
Supravalvular Aortic Stenosis

• Supravalvular
• Associated Elfin facies
• Hypercalcemia
• Peripheral pulmonic stenosis
• Thrill palpation in suprasternal notch or R but
  not L carotid artery
• Increased A2

9
Subvalvular Aortic Stenosis

• Subvalvular
• Presents with a high doppler velocity on outflow
  tract with normal AV on echo.
• Frequent AR due to aortic valve jet
• Looks like HOCM on echo with LAM
• Two subtypes
• Discrete- 10, sec to subvalvular ridge
• Tunnel

10
Valvular Aortic Stenosis

• Valvular
• Congenital (1-30 yrs old)
• Bicuspid (40-60 yrs old)
• Rheumatic (40-60 yrs old)
• Senile degenerative (gt70 yrs old)

11
Bicuspid Aortic Valve

• The most common congenital cardiac abnormality is
  bicuspid aortic valve affecting 1-2 of the U.S.
  population.
• Over time, one-third to one-half of such valves
  become stenotic, with significant narrowing of
  the aortic orifice typically developing in the
  5th and 6th decades of life.

12
Aortic Stenosis Key Points

• MCC of AS is senile degenerative changes
• In patients with AS due to rheumatic dz r/o
  silent mitral stenosis.
• Bicuspid or rheumatic should be suspected in pt
  with AS presenting in 5th or 6th decade of life.

13
Pathophysiology

• Increase in afterload
• Decrease in systemic and coronary flow from
  obstruction
• Progressive hypertrophy

14
Classic symptom triad

• Dyspnea
• Angina
• Syncope

15
Classic symptom triad

• Once any of these classic symptoms develop,
  prognosis dramatically worsens.
• Thus, within 5 years of the development of
  angina, approximately 50 of patients will die
  unless aortic valve replacement is performed.
• For syncope, 50 survival is 3 years
• For congestive heart failure, 50 survival is
  only 2 years unless the valve is replaced.
• Angina 5, Syncope 3, and CHF 2.

16
Characteristic Physical findings

• Dampened upstroke of carotid artery
• Sustained bifid left ventricular impulse
• Absent A2
• Late-peaking systolic ejection murmur
• A concomitant systolic thrill indicates the
  presence of AS (mean gradient gt50mm Hg)
• Of note if you have significant Physical finding
  and symptoms, you must rule out severe AS.

17
Aortic Stenosis

• Patients with the physical findings of AS should
  undergo selected laboratory examinations,
  including an ECG, a chest x-ray, and an
  echocardiogram.
• The 2-D echocardiogram is valuable for confirming
  the presence of aortic valve disease and
  determining left ventricular (LV) size and
  function, degree of hypertrophy, and presence of
  other associated valve disease.

18
EKG

• Usually shows NSR with LVH
• Note If AF is present, concomitant mitral valve
  disease or thyroid dz must be suspected.

19
Recommendations for Echocardiography in AS

• Class 1
• Diagnosis and assessment of severity of AS.
• Assessment of LV size, function, and/or
  hemodynamics.
• Reevaluation of patients with known AS with
  changing symptoms or signs.
• Assessment of changes in hemodynamic severity and
  ventricular compensation in patients with known
  AS during pregnancy.
• Reevaluation of asymptomatic patients with severe
  AS.
• Class IIa
• Reevaluation of asymptomatic patients with mild
  to moderate AS and evidence of LV dysfunction or
  hypertrophy.
• Class III
• Routine reevaluation of asymptomatic adult
  patients with mild AS having stable physical
  signs and normal LV size and function.

20
ECHO

• Modified Bernoulli equation (?P4v2) used to
  calculate gradient.
• A maximal instantaneous and mean AV gradient is
  derived from the continuous-wave Doppler velocity
  across the aortic valve.
• AVA can be estimated by continuity equation
• AVALVOTarea LVOTTVI
• AVTVI

21
ECHO/Doppler Pit Falls

• Will underestimate AS if Doppler beam is not
  parallel to AS velocity jet.
• Will rarely over-estimate mean gradient
• Severe anemia (hemoglobin lt8.0 g/dl)
• Small aortic root
• Sequential stenoses in parallel (coexistent LVOT
  and valvular obstruction)

22
Severity of AS
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26
Cath data

• Pull back tracing can be used in pt with NSR
  but not accurate in irregular rhythms or low-out
  put states.
• In low cardiac output, the stenosis may be
  severe, with a mean gradient lt50mm Hg per echo.
• Gorlin equation can be used to calculate AVA from
  pressure gradients, independent of CO.
• AVA (1000)(CO)
• (44)(SEP)(HR)(v?P)

27
Hakke formula

• Simple way to do things!
• Used to calculate AV area
• AVACO/?(p-p gradient)

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30
Treatment

• AVR is clearly indicated in symptomatic patients.
  
• Management decisions are more controversial in
  asymptomatic patients.
• Patients with severe AS, with or without
  symptoms, who are undergoing CABG should undergo
  AVR at the time of revascularization.
• There is general consensus that patients with
  moderate AS (e.g., mean pressure gradient 30 mm
  Hg) should undergo AVR at the time of CABG, but
  controversy persists regarding the indications
  for concomitant AVR at the time of CABG in
  patients with milder forms of AS.

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32
Treatment Key Points

• Aortic valve replacement is indicated for
  patients with symptoms of severe AS, regardless
  of the LV ejection fraction.
• Coronary angiography may not be required
  preoperatively in younger patients without risk
  factors for CAD.
• Percutaneous aortic balloon valvuloplasy is
  reserved only for critically ill patients as a
  bridge to surgery.

33
Asymptomatic patients with Severe AS

• The most common cause of death in patients with
  severe aortic stenosis is an operation The
  prevailing notion.
• Surgery should be performed at the onset of
  symptoms or LV systolic dysfunction.

34
AS w/ low output/low gradient

• Exercise testing maybe performed to document
  exercise tolerance and hemodynamic response in
  pts with low CO.

35
AS w/ low output/low gradient
36
Question

• 55yo presents with DOE for past 6 months which is
  worsening. Pt has no significant PMH. PE
  carotid upstroke 2 delay but full volume, Second
  heart sound is single. There is a 3/6 SEM at
  RSB with mid-peak which ends at second heart
  sound. Echo mild LVH, EF 65, AV calcified and
  restricted. LVOT diameter is 2.0cm. Peak AV
  velocity is 2.5 m/sec with mean gradient of 18mm
  HG. LVOT velocity is 1.0 m/sec.
• What is the AVA? A. 0.5 cm2 B. 0.8 cm2 C.
  1.0 cm2 D. 1.2 cm2

37
Answer

• AVA can be estimated by continuity equation
• LVOT diameter is 2.0cm. Peak AV velocity is 2.5
  m/sec with mean gradient of 18mm HG. LVOT
  velocity is 1.0 m/sec.
• The first step is to calculate the
  cross-sectional area of LVOT, as follows CSA
  (LVOT) p r2 p(d/2)2. CSA (LVOT) p r2
  p(d/2)2 p(2/2)2 p(1)2 p
• The formula for calculated aortic valve area
  (AVA) isAVA (cm2) CSA (LVOT) x (Vmax LVOT)
  Vmax AoV.
• In this case, AVA p cm2 x (1.0 m/sec 2.5
  m/sec)
• 3.14 cm2 x (0.4 m/sec)
• 1.2 cm2

38
Question

• What is the most likely etiology of this patient
  valve disease?  A. Bicuspid.  B. Inflammatory
  process.  C. degenerative calcific disease.
   D. Congenital unicuspid valve.

39
Question

• What is the most likely etiology of this patient
  valve disease?  A. Bicuspid.  B. Inflammatory
  process.  C. degenerative calcific disease.
   D. Congenital unicuspid valve.

40
Question

• What is the next step in the management of this
  patient?  A. Dobutamine Echo.  B. Medical
  treatment.  C. Medical treatment but repeat
  study in 6 months.  D. R/L heart cath with CO,
  AV gradient and coronary angio.  E. Coronary
  angiogram and AVR.

41
Answer

• What is the next step in the management of this
  patient?
•  A. Dobutamine Echo- only for Low CO pt with EF
  65
•  B. Medical treatment-pt with symptoms,
•  C. Medical treatment but repeat study in 6
  months.
•  D. R/L heart cath with CO, AV gradient and
  coronary angio. Gives you more info
• E. Coronary angiogram and AVR- AVA 1.2 per echo
  need more info before AVR

42
Question

• Cardiac Cath Aortic pressure 130/70 mmHg. LV
  pressure 180/15 mmHg. CO via thermo-dilutioon is
  3.5 L/min. SEF is 280 ms at HR of 70bpm. Oxygen
  consumption is 270 cc/min. Pulmonary artery
  saturation is 64 and femoral artery saturation
  is 98. Coronary arteries are normal
• What is the calculated AVA?
•  A. 0.5 cm2 B. 0.8 cm2 C. 1.0 cm2 D.
  1.2 cm2

43
Answer

• Cardiac Cath Aortic pressure 130/70 mmHg. LV
  pressure 180/15 mmHg. CO via thermo-dilutioon is
  3.5 L/min.
• What is the calculated AVA?
•  A. 0.5 cm2 B. 0.8 cm2 C. 1.0 cm2 D.
  1.2 cm2
• Use Hakke formula
• AVACO/?(p-p gradient)
• AVA3.5 /?(180-130)
• 3.5/7 0.5 cm2

44
Question

• What is the next step in the management of this
  patient?
• A. Medical therapy
• B. AVR- homograft
• C. AVR- mechanical
• D. AVR - Ross procedure

45
Answer

• What is the next step in the management of this
  patient?
• A. Medical therapy
• B. AVR- homograft
• C. AVR- mechanical
• D. AVR - Ross procedure
• Less then 65yo without CI Mechanical valve TOC.

46
Question

• The calculated aortic valve area using LVOT
  diameter 2cm, Vmax AV 4 m/sec, and Vmax LVOT
  0.8 m/sec is  A. 0.6cm².  B. 1.0cm².  C.
  2.0cm².  D. 1.2cm².  E. 1.5cm².

47
Answer

• The correct answer is A.The first step is to
  calculate the cross-sectional area of LVOT, as
  follows CSA (LVOT) p r2 p(d/2)2. The
  formula for calculated aortic valve area (AVA)
  isAVA (cm2) CSA (LVOT) x (Vmax LVOT) Vmax
  AoV. In this case, AVA p cm2 x (0.8 m/sec 4
  m/sec)
• (3.14)(0.2) 0.6cm2

48
Question

• A 50-year-old man is referred with a murmur of
  aortic stenosis--an incidental finding on a
  routine physical examination. The patient denies
  cardiac symptoms. The physical examination was
  unremarkable except for a grade IV/ VI late
  crescendo murmur typical of aortic stenosis and
  an S4 gallop. The resting ECG showed minimal ST
  and T changes but no voltage criteria for LVH.
  The Doppler echocardiogram showed a mean gradient
  of 60 mmHg with thickening of the ventricular
  walls but a normal ejection fraction. The patient
  underwent a Bruce protocol exercise test and quit
  after 5 minutes because of dyspnea. The thallium
  image showed no localized defect.

49
Question

• What is the most appropriate management strategy
  at this time?  A. Follow the patient with
  echocardiography every 6 months.  B. Perform a
  dobutamine stress echo.  C. Start enalapril.
   D. Follow the patient with an exercise stress
  test every 6 months.  E. Recommend aortic valve
  replacement.

50
Answer

• The correct answer is E.
• This patient has severe aortic stenosis. Although
  the patient claims to be asymptomatic, his poor
  performance on the exercise test indicates he is
  not. In fact, patients with "asymptomatic" aortic
  stenosis have a 2-4 risk of cardiac death.
  Usually, however, symptoms develop 1-3 months
  before death.
• In view of the low surgical risk and good
  long-term result of mechanical prosthetic valves,
  plus the definite incidence of sudden death in
  symptomatic patients who are not operated upon,
  the prudent course is to recommend aortic valve
  replacement.
• This patient has a low risk of associated
  coronary artery disease, but this would need to
  be evaluated by catheterization preoperatively

51
Question

• Which one of the following is the most reliable
  measurement of the severity of aortic stenosis in
  a 75-year-old patient with congestive heart
  failure, a calcified aortic valve, and an
  ejection fraction of 25?  A. Aortic valve area
  at the time of cardiac catheterization.  B.
  Pressure gradient across the valve.  C.
  Angiographic appearance of the valve.  D.
  Dobutamine stress echo Doppler.  E.
  Radionuclide exercise study.

52
Answer

• The correct answer is D.For reasons that are
  not totally clear, the Gorlin formula for aortic
  valve area becomes less reliable in patients with
  calcific valves and a low ejection fraction and a
  low cardiac index. Such patients typically have
  only a modest pressure gradient across the valve.
  The angiographic appearance of the valve is not
  reliable for distinguishing between moderate and
  severe disease when the valves are calcified.
  Likewise, a radionuclide angiogram would be of
  limited use in this setting (and the patient
  probably could not perform it). Recent evidence
  suggests that a dobutamine echo-Doppler study is
  a more reliable method of calculating aortic
  valve severity when the cardiac output is
  increased by dobutamine. When the aortic stenosis
  is significant, the gradient will significantly
  increase.

53
Question

• Which of the following is least likely to be a
  determining factor in the operative risk of
  valvular aortic stenosis?  A. An aortic valve
  area of less than 0.7 cm².  B. The presence of
  coronary artery disease.  C. Left ventricular
  systolic dysfunction.  D. The presence of
  atrial arrhythmias.  E. Coexisting aortic
  regurgitation.

54
Answer

• The correct answer is A.The valve area defines
  severity of aortic stenosis, but not the risk of
  operation. The presence of coronary artery
  disease increases risk in most studies--up to 2X
  in some. Failure to bypass significant disease at
  the time of valve replacement substantially
  increases risk. Severe LV dysfunction with its
  associated symptoms and signs of congestive heart
  failure increases risk, which parallels
  functional class. Patients in atrial fibrillation
  have a higher risk of surgery. They are generally
  later in the natural history of the disease and
  have other cardiovascular morbidity. Coexisting
  aortic regurgitation does increase risk in some
  studies.

55
Question

• The following hemodynamic data were obtained in
  patients with isolated valvular aortic stenosis.
  Which of the following is consistent with severe
  aortic stenosis?
• A. Mean gradient across the aortic valve of 23
  mmHg with cardiac index of 3.0 l/min/m², and
  normal left ventricular function.
• B. Mean gradient across the aortic valve of 28
  mmHg, cardiac index of 1.8 l/min/m², left
  ventricular ejection fraction of 29 after
  dobutamine infusion, the aortic valve gradient is
  28 mmHg, and the cardiac index is 3.2 l/min/m².
• C. Mean gradient across the aortic valve of 32
  mmHg, cardiac index of 1.5 l/min/m², and LV
  ejection fraction of 28 after dobutamine
  infusion, mean gradient across the aortic valve
  is 50 mmHg and cardiac index 3.0 l/min/m².
• D. Mean gradient across the aortic valve of 25
  mmHg, cardiac index of 3.5 l/min/m² with an LV
  ejection fraction of 35.

56
Answer

• The correct answer is C.The interpretation of
  pressure gradients must include an analysis of
  flow. The difficult clinical question is whether
  the low gradient, usually in the 20-30 mmHg
  range, is associated with severe aortic stenosis
  masked by low flow. The flow may be so low that
  even in the presence of a severe anatomic
  narrowing, the gradient is low--thus the need to
  remeasure the gradient after inducing an increase
  in flow. In the first example, a mean gradient
  of 23 mmHg with normal LV function and cardiac
  index is consistent with mild aortic stenosis.

57
Question

• A 62-year-old man presents with chest pain
  typical of angina pectoris, New York Heart
  Association functional class II. Physical
  examination reveals a grade III/VI musical
  systolic ejection murmur at the left sternal
  border, radiating to the neck. A2 is decreased
  but present. Echocardiography shows left
  ventricular hypertrophy, a normal ejection
  fraction, and a calcified aortic valve with a
  valve area of 0.8cm2. He undergoes a coronary
  arteriogram, which shows a diffusely calcified
  aortic valve with reduced mobility and a pressure
  gradient of 45mm across the valve. The left
  ventricle appears normal. There is, however, an
  85 diameter stenosis of both the proximal left
  anterior descending and proximal right coronary
  artery.

58
Question

• Which one of the following therapeutic approaches
  offers the most favorable long-term result for
  this patient?
• A. Medical therapy with beta blockers, aspirin,
  and enalapril and follow-up every 6 months until
  the aortic stenosis worsens.
•  B. Coronary artery bypass grafting, including a
  left internal mammary artery and aortic valve
  replacement with a bioprosthesis.
• C. Coronary artery bypass grafting, including an
  internal mammary artery and aortic valve
  replacement with a mechanical prosthesis.
•  D. Coronary artery bypass grafting, including an
  internal mammary artery, but delaying aortic
  valve replacement until the lesion is more
  severe.
• E. Multivessel angioplasty now, following the
  patient until the aortic valve disease becomes
  more severe.

59
Answer

• The correct answer is C.This patient has severe
  coronary artery disease requiring interventional
  treatment. He has concurrent, moderately severe
  aortic stenosis that is nearly bad enough to
  warrant surgical repair on its own. There would
  be a high surgical risk to fixing the coronary
  lesion but not the aortic valve, as there would
  be also for multivessel angioplasty. He
  probably is not a candidate for medical therapy,
  in view of the severity of both his valve and
  coronary artery disease. Postponing aortic valve
  surgery and performing bypass only now would
  expose him to operative mortality in the
  excessively high 15-25 range.

60
Answer

• This patient might be expected to live 20 years,
  in view of his normal left ventricle and the
  favorable results of internal mammary bypass.
  Thus, his best outcome would be to have a
  coronary artery bypass operation and simultaneous
  aortic valve replacement.
• Although the combined surgery slightly increases
  the operative mortality for aortic valve
  replacement (5-10), it is still significantly
  less than that for a re-do operation to replace
  the aortic valve sometime after the bypass
  procedure has been performed.

61
Question

• An 18-year-old college freshman presents with 3
  days of flu-like symptoms and sharp right chest
  pain with inspiration. Physical examination
  shows BP 100/70, pulse 88 regular, temp 100F,
  respiration rate 20. HEENT is negative except for
  boggy nasal mucosa. JVP is normal. Carotids with
  slow upstrokes, palpable systolic thrills, and
  systolic bruits. Normal breath sounds, lungs
  clear, but he splints inspiration, complaining of
  pain on inspiration along right costal margin.
  S1 is normal, S2 with increased A2, ejection
  click and grade IV/VI systolic ejection murmur
  upper right sternal border radiating to the neck.
  No diastolic murmur. Abdomen negative.
  Extremities with 2 pulses, no brachial-femoral
  delay. No edema, cyanosis, clubbing.

62
Question

• ECG shows increased precordial voltage.
• Chest x-ray normal.
• Echo-Doppler study shows a 50 mmHg aortic valve
  gradient, mobile "doming" leaflets, mild aortic
  regurgitation, aortic valve area 1.0 cm2, mildly
  increased LV mass, LV ejection fraction 75. No
  pericardial effusion.

63
Question

• Which one of the following is appropriate next?
   A. Treat him symptomatically for viral
  infection, discuss antibiotic prophylaxis, and
  arrange follow-up visit.  B. Refer for aortic
  valve replacement as soon as possible.  C.
  Treat with penicillin and aspirin and start
  rheumatic fever prophylaxis.  D. Eliminate
  balloon valvotomy as a therapeutic option due to
  age and presence of aortic regurgitation.  E.
  Draw blood cultures and initiate IV antibiotics
  for treatment of endocarditis.

64
Answer

• The correct answer is A.
• Because the patient has viral pleurisy and an
  exam consistent with moderate aortic stenosis,
  likely congenital, prophylaxis and regular follow
  up are important.
• Referring for aortic valve replacement is
  inappropriate because aortic stenosis is moderate
  and asymptomatic, so follow-up is appropriate.
  You could consider a valvotomy, as gradient is
  50mm and he has LVH, but not valve replacement.
  There are insufficient criteria for rheumatic
  fever and the echo findings are classic for
  congenital AS. Although he could have a
  valvotomy, he has a mobile, bicuspid valve with
  mild and inaudible aortic regurgitation and no
  contraindications. Making a distinction between
  whether he is an adolescent, reaching pediatric
  criteria for intervention, or an adult is of no
  consequence in this instance. Blood cultures and
  IV antibiotics are not called for because viral
  syndrome is likely. He should instead be
  instructed to monitor fever, report if high and
  chills, and be given no antibiotics. Blood
  cultures could be drawn, but likely will be
  negative.

65
Question

• A 77-year-old man with chronic angina pectoris of
  3 years duration has had increasing symptoms for
  the past 6 weeks with episodes at rest, nocturnal
  episodes, and prolonged episodes with effort
  often requiring two to three sublingual
  nitroglycerins (instead of the usual one or rest)
  for relief. His overall health is good. He is
  known to have aortic stenosis of moderate degree
  with typical findings. His blood pressure is
  140/80, heart rate of 72, his carotid pulses show
  delayed upstroke. There is no jugular venous
  hypertension or basal thrill. The apical impulse
  is localized but enlarged and forceful. There is
  no aortic second sound and a typical musical
  murmur of calcific aortic stenosis.

66
Question

• His electrocardiogram shows moderate voltage for
  LVH, flattening of the T waves, and left atrial
  abnormality and no suggestion of myocardial
  infarction. An angiographic study showed major
  narrowings in the proximal portions of all three
  of his coronary trunks, diffuse disease
  throughout the arteries but good distal vessels.
  There is moderate narrowing in the LMCA. A
  pullback mean gradient was 30 mmHg. The valve is
  heavily calcified. The ejection fraction was
  estimated at 55-60

67
Question

• Which of these management strategies is
  preferred?  A. CABG without aortic valve
  replacement.  B. Increase medical therapy
  adding a beta blocker.  C. Perform a thallium
  test to localize ischemia, and perform
  intentionally incomplete revascularization
  utilizing PCI.  D. Dobutamine stress test to
  study ischemia and evaluate the gradient during
  stress.  E. CABG with aortic valve replacement.
  

68
Answer

• The correct answer is E.This problem of senile
  calcific aortic stenosis with major coronary
  atherosclerosis is a vexing problem occurring
  with increasing frequency in the elderly
  population. The issue here is to predict the
  progression of his aortic stenosis. Although a
  spectrum of opinions exist, in centers with
  excellent cardiac surgery, option E, CABG with
  valve replacement, is preferred. Although the
  combination surgery modestly increases risk, the
  chance of a need for valve replacement during the
  next 3-5 years is quite high, so isolated CABG is
  problematic in reference to a "long term
  solution" to this elderly mans problem. Though
  data are sparse and fragmentary, particularly in
  elderly patients, data indicate aortic stenosis
  of moderate severity, particularly with heavy
  calcification, is likely to become symptomatic
  and require valve replacement within 5 years.
  Avoiding an emergency operation is important, and
  the risk of two open-heart surgical procedures in
  patients over the age of 75 during a 3-5 year
  period is significantly more risky than doing a
  single procedure.

69
Answer

• Although a PCI procedure in the elderly is
  appealing (C), the extent of disease in this
  patient coupled with his diabetes makes PCI
  problematic. However, if PCI were successful in
  relieving his angina, it would provide relief for
  several years during which the aortic stenosis
  could progress. There is no advantage and perhaps
  some minimal risk in dobutamine
  echo-cardiographic study (D) in this patient.
  Although its role in assessing aortic stenosis
  remains uncertain, its chief value is in patients
  who have a low gradient (such as this patient)
  but with reduced ventricular function (which is
  not the case in this patient) in an effort to
  differentiate the effects of afterload increase
  from reduced contractility on the ventricular
  dysfunction. Medical therapy (B) is extremely
  unlikely to be useful in this patient, with
  worsening of angina considering his age, AS, and
  overall duration of his complaint.

70
Question

• All of the following are echocardiographic
  evidence for aortic stenosis except  A.
  Concentric LVH.  B. Markedly thickened and
  restricted aortic valve leaflets.  C. TVI
  LVOT/TVI AV lt 0.25.  D. V (max) AV gt 4.5m/sec.
   E. TVI (AV)/TVI (LVOT) lt 0.25.

71
Answer

• The correct answer is E.The dimensionless index
  is TVI LVOT/TVI AV. If this is lt 0.25, then a
  patient has severe aortic stenosis. Patients with
  significant aortic stenosis have LVH as a
  response to the increased workload on the LV.
  Patients with aortic stenosis have markedly
  thickened and restricted aortic leaflets unless
  they have an unusual form of congenital aortic
  stenosis, such as a unicuspid aortic valve. A
  Vmax gt 4.5m/sec across the aortic valve would
  correspond to a peak pressure gradient of 81
  mmHg, which would be consistent with severe
  aortic stenosis.

72
Question

• You are responsible for the care of a vigorous
  72-year-old man with acquired degenerative
  calcific valvular aortic stenosis, accompanied by
  mitral regurgitation and calcification of the
  mitral annulus.
• He has survived infective endocarditis with
  multiple positive cultures for Streptococcus
  mutans, which you judged to be of dental origin
  although there had been no specific dental
  intervention related temporally with the onset of
  symptoms.
• Based on catheterization data completed during
  his antibiotic course, you feel that aortic valve
  replacement and inspection of the mitral valve
  and adjacent structures are indicated. The
  patient has 11 remaining teeth that are in poor
  repair.

73
Question

• Which one of the following is the best plan?
• A. Ignore the dental status in deference to the
  more serious valvular heart disease.
• B. Discharge the patient to the care of his
  dentist to permit cautious dental extraction of
  one to two teeth per visit.
• C. Schedule full-mouth extraction well in advance
  of the anticipated cardiac surgery.
• D. Schedule full-mouth extraction synchronous
  with cardiac surgery, thus avoiding a second
  anesthesia.
• E. Delay all dental procedures until after the
  cardiac surgery.

74
Answer

• The correct answer is C.This patient's dental
  hygiene probably is the source of his
  endocarditis, demonstrating that a dental
  procedure is indeed not required for endocarditis
  to occur. In terms of his ongoing risk for
  recurrent endocarditis, proper management of his
  dentistry preoperatively is perhaps the most
  important factor. Once his prosthetic valve is
  implanted, he is then forever maximally at "high
  risk" such that any issues that can be addressed
  safely and reasonably before cardiac surgery
  should be done. Removal of all his teeth at
  once is a procedure that dental surgeons can
  accomplish with little difficulty, thereby
  undertaking the risk of extraction-related
  bacteremia once rather that several times. The
  serial approach, in addition to being
  unnecessary, would raise the additional issue of
  cumulative antibiotic resistance via the
  chemoprophylaxis regimens, which would need to be
  given for each of the procedures.

75
Answer

• Performing this procedure in conjunction with the
  cardiac surgery (in any sequence) would simply
  add unnecessary stress (as well as bacteremia) to
  a time that is already high-risk in and of
  itself. Delaying the dentistry would simply make
  likely the occurrence of prosthetic valve
  endocarditis (PVE) via the same mechanisms
  responsible for the original infectious illness.
  Careful preoperative dental evaluation is
  recommended so that required dental treatment can
  be completed at least several weeks prior to
  cardiac surgery whenever possible. Such measures
  may decrease the incidence of late postoperative
  endocarditis.

76
Question

• Catheter-delivered balloon expansion techniques
  are now the treatment of choice for which one of
  the following lesions in adults?  A. Valvular
  pulmonic stenosis.  B. Valvular aortic
  stenosis.  C. Coarctation of the aorta.  D.
  Ebstein's anomaly of the tricuspid valve.  E.
  Severe mitral stenosis/regurgitation.

77
Answer

• The correct answer is A.Although catheter
  balloon valvuloplasty and aortoplasty have been
  attempted in all these conditions, only pulmonary
  valvotomy has achieved a success level consistent
  with being the treatment of choice in adults.
  Aortic stenosis responds initially to balloon
  expansion and may serve as a bridge to valve
  replacement surgery, but is associated with rapid
  restenosis. Success rates with coarctation and
  Ebstein's anomaly are not uniform enough to
  displace surgery except in selected patients.
  Mitral stenosis in the absence of severe
  subvalvular disease can be successfully treated
  by balloon valvuloplasty, but the presence of
  moderate to severe regurgitation is an indication
  for surgery.

78
Work Cited

• Mayo Board Review
• ACCSAP V
• Up-To-Date
• ACC/AHA Guidelines

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The End