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Case 185

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A 84-year-old male patient presented a proximal humeral fracture after suffering ground level fall associated with syncope. Reports repetitive syncope, angina and slight limitation by shortness of breath during moderate exertion. As comorbities he has hypertension, type 2 diabetes mellitus, dyslipidemia, stage G3b chronic kidney disease (CKD) − glomerular filtration rate (GFR) of 33.3 L/min per 1.73 m2. In use of ACE inhibitors, diuretics and nitrate. On physical examination, he presented decreased breath sounds in pulmonary bases, grade II/IV ejection systolic murmur, heard best in second intercostal space on the right, with harsh quality, radiating to neck . Also, it was observed that arterial pulse was reduced in amplitude and delayed in occurrence. Electrocardiogram (ECG) showed regular sinus rhythm, left ventricular hypertrophy. Laboratory tests: creatinine: 1.9; Hb: 11.5; Htc: 39.

Based on clinical examination and laboratory tests, which is the most likely diagnosis and the most adequate procedure?

a) Bicuspid aortic valve and use of diuretics and ACE inhibitors.

25%

b) Carotid stenosis and treatment with anti-platelet.

25%

c) Calcified aortic stenosis with treatment of percutaneous aortic valve implantation (TAVI).

25%

d) Calcified aortic stenosis and surgery with aortic valve replacement.

25%
   

Image Analysis

Video 1: Doppler echocardiographyshowing a valve with aortic stenosis (AS) with calcified center hole 0.7 cm² and systolic gradient In-LV/AS = 80 mmHg with mobility and reduced valve area.

 

Video 2: hemodynamic study highlighting the aortography performed just before TAVI. It is possible to see calcified aortic valve, tricuspid very disabled, its brochures and small contrast reflux into the left ventricle.

 

Video 3: Post-treatment Aortography

We can notice the difference between the sick and the implanted valve: the latter one allows a free blood flow from left ventricle to aorta. 

Highlights

- Aortic Stenosis Dgenerative – Aortic valve stiffness due to the deposition of calcium and lipids, which compromises the blood passing from the left ventricle.

- Aortic stenosis is manifested by syncope and/or angina and/or heart failure with left ventricular failure

- Surgical aortic valve replacement - the gold standard treatment of aortic stenosis. However, it is contraindicated in case of high surgical risk.

- Transcatheter aortic valve implantation (TAVI) – alternative procedure for patients contraindicated surgical replacement of the aortic valve.

References

- Tarasoutchi F, Montera MW, Grinberg M, Barbosa MR, Piñeiro DJ, Sánchez CRM, Barbosa MM, Barbosa GV et al. Diretriz Brasileira de Valvopatias - SBC 2011 / I Diretriz Interamericana de Valvopatias - SIAC 2011. ArqBrasCardiol 2011; 97(5 supl. 1): 1-67.

- Thibault GE, DesanctisRW, BucleyMJ. Bibliomed [Online]. Disponível em http://www.bibliomed.com.br/bibliomed/books/livro11/cap/cap19.htm. Access in 15/10/2014.

- Leon MB. N Engl J Med 2010;363:1597-1607.

- Vahanian A. Eur Heart J 2008;29:1463-1470.

- Site STS (Society of Thoracic Surgeons)

- Varadarajan P. Euro J CardiothoracSurg2006;30:722-727.

Authors

- Flávio Coelho Barros, 4th year medical student at UFMG School of Medicine E-mail: flavioc[at]icloud.com

- Marcelo de Oliveira e Britto Perucci, 4th year medical student at UFMG School of Medicine. 

E-mail: marceloperucci[at]gmail.com

- Vítor Eugênio Ribeiro, 4th year medical student at UFMG School of Medicine. E-mail: eribeiro.vitor[at]gmail.com

- Letícia Horta Guimarães, 6th year medical student at UFMG School of Medicine E-mail: leticiahorta[at]gmail.com

Supervisor

- Marcos Antonio Marino. Coordinator of Endovascular Surgery Department of Madre Teresa-Belo Horizonte Hospital.

E-mail: marcosamarino[at]yahoo.com.br

- Ronald de Souza, Endovascular Surgery specialist in Madre Teresa-Belo Horizonte Hospital.

E-mail: ronaldturco[at]gmail.com

Reviewers

André Guimarães, Bárbara Queiroz, Luanna Monteiro, Hércules Riani, Luisa Bernardino, Daniela Braga, Júlio Guerra and prof. Viviane Parisotto Marino.

Translated by

Ana Júlia Furbino Dias Bicalho, 6th year medical student at UFMG School of Medicine. E-mail: anajuliabicalho[at]gmail.com

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