Description
The definition of severe aortic stenosis has classically and retrospectively been based on the natural history of patients with medically managed aortic stenosis and preserved left ventricular function in an era where surgical aortic valve replacement was the sole therapy. We now recognize that this disease is more heterogeneous and includes important subsets of patients with low stroke volume index (low flow) and low-gradients with reduced (classical) or preserved (paradoxical) ejection fraction. These patients pose diagnostic and treatment dilemmas, requiring a comprehensive assessment with integration of multimodality imaging, testing, and clinical assessment. Surgery in these patients has been associated with higher operative mortality and lower long-term survival.
Summary Listen
- A 69-year-old male patient with several cardiovascular risk factors presented with worsening shortness of breath and possible angina. He has a history of a triple vessel bypass surgery, subsequent stenting of a saphenous vein graft, and now exhibits symptoms suggesting both coronary artery disease and aortic stenosis. Initial assessments revealed normal vitals but with concerning signs like elevated Pro-BNP levels and an ejection systolic murmur.
- Echocardiography indicated a trileaflet calcific aortic valve with a borderline mean gradient and a valve area suggestive of significant stenosis. The patient's ejection fraction was reduced, indicating left ventricular impairment, and a low stroke volume pointed to a low-flow state. These findings classify the patient as having a low-flow, low-gradient aortic stenosis.
- The diagnostic challenge was discerning whether the patient's symptoms were primarily due to coronary artery disease or the aortic stenosis. While a dobutamine stress echo was considered, it was deemed too risky due to the patient's frequent ectopic beats. Instead, a multi-slice CT scan was performed to assess the aortic valve calcium score.
- The CT scan revealed a high aortic valve calcium score, strongly suggesting true severe aortic stenosis despite the low gradient. Given the patient's high surgical risk score, a transcatheter aortic valve replacement (TAVR) was chosen as the preferred intervention. Pre-procedural CT scans were used to assess aortic root dimensions, coronary heights, and to identify the optimal co-planar view for valve implantation.
- TAVR was successfully performed under general anesthesia, resulting in improved valve gradients. The procedure involved percutaneous access to the common femoral artery using a large-bore sheath. A balloon-expandable valve was positioned and deployed within the native aortic valve. Post-procedure assessment showed a reduction in peak and mean gradients across the implanted valve.
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