Critical decompensated aortic stenosis – a cascading approach to treatment

    Authors

    Keywords

    aortic stenosis, transcatheter aortic valve implantation

    DOI

    https://doi.org/10.15836/ccar2016.620

    Full Text

    A 91-year-old patient was admitted with symptoms and signs of heart failure. Transthoracic echocardiography ( Figure 1 ) revaled severe aortic stenosis (max gradient 122 mmHg, mean 62 mmHg, AVA 0.4-0.5 cm2), moderate-severe mitral and tricuspid regurgitation, reduced left ventricular systolic function (LVEF 30%) and high pulmonary hypertension (PAP 90-95 mmHg). Coronary angiography showed no significant coronary artery disease. Due to age and poor functional status (NYHA IIIB / IV), aortic valve surgery was estimated as high risk, and it was decided to perform transcatheter aortic valve implantation (TAVI). Patient was presented to TAVI Heart Team. Meanwhile, the patient underwent successful balloon aortic valvuloplasty (BAV), with a consequent drop in the max gradient between the left ventricle and the aorta from 91 to 52 mmHg, without significant aortic regurgitation. After BAV and intensive diuretic therapy, left ventricle volume unloading and functional recovery was accomplished. Six months later, the patient underwent successful transfemoral TAVI (CoreValve 26). Control echocardiography ( Figure 2 ) revealed the recovery of left ventricular systolic function (LVEF 50-55%) with normal function of the CoreValve (max gradient 24 mmHg, mean 10 mmHg), moderate mitral and tricuspid regurgitation and some reduction of pressures in the pulmonary circulation (PAP 45 mmHg). The patient was discharged on the 7th post-interventional day, mobilized, in NYHA II functional status. The apical four chamber view and Doppler aortic valve continuous wave with first presentation, before intervention. The apical four chamber view and Doppler aortic valve continuous wave after transcatheter aortic valve implantation. Balloon dilatation of the aortic valve may successfully bridge the period until the final decision on the definite severe aortic stenosis treatment option. Even in very old patients, symptom relief in terminal stage of heart failure after BAV is raising the quality of life. It also gives an opportunity for patients to undergo more technically demanding, and more durable procedures. Heart team has a central role in this decision-making process. ( 1 )

    Cardiologia Croatica
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    Critical decompensated aortic stenosis – a cascading approach to treatment

    Extended Abstract
    Issue12
    Published
    Pages620-621
    PDF via DOIhttps://doi.org/10.15836/ccar2016.620
    aortic stenosis
    transcatheter aortic valve implantation

    Authors

    Blanka Ćuk*ORCIDCroatia
    Marija BegićORCIDCroatia
    Marija KrižićORCIDCroatia
    Vlatka Rešković LukšićORCIDCroatia
    Dejan DošenORCIDCroatia
    Željko BaričevićORCIDCroatia
    Maja StrozziORCIDCroatia
    Blanka GlavašCroatia
    KonjaORCIDCroatia
    Joško BulumORCIDCroatia
    Jadranka ŠeparovićCroatia
    HanževačkiORCIDCroatia

    Full Text

    A 91-year-old patient was admitted with symptoms and signs of heart failure. Transthoracic echocardiography ( Figure 1 ) revaled severe aortic stenosis (max gradient 122 mmHg, mean 62 mmHg, AVA 0.4-0.5 cm2), moderate-severe mitral and tricuspid regurgitation, reduced left ventricular systolic function (LVEF 30%) and high pulmonary hypertension (PAP 90-95 mmHg). Coronary angiography showed no significant coronary artery disease. Due to age and poor functional status (NYHA IIIB / IV), aortic valve surgery was estimated as high risk, and it was decided to perform transcatheter aortic valve implantation (TAVI). Patient was presented to TAVI Heart Team. Meanwhile, the patient underwent successful balloon aortic valvuloplasty (BAV), with a consequent drop in the max gradient between the left ventricle and the aorta from 91 to 52 mmHg, without significant aortic regurgitation. After BAV and intensive diuretic therapy, left ventricle volume unloading and functional recovery was accomplished. Six months later, the patient underwent successful transfemoral TAVI (CoreValve 26). Control echocardiography ( Figure 2 ) revealed the recovery of left ventricular systolic function (LVEF 50-55%) with normal function of the CoreValve (max gradient 24 mmHg, mean 10 mmHg), moderate mitral and tricuspid regurgitation and some reduction of pressures in the pulmonary circulation (PAP 45 mmHg). The patient was discharged on the 7th post-interventional day, mobilized, in NYHA II functional status. The apical four chamber view and Doppler aortic valve continuous wave with first presentation, before intervention. The apical four chamber view and Doppler aortic valve continuous wave after transcatheter aortic valve implantation. Balloon dilatation of the aortic valve may successfully bridge the period until the final decision on the definite severe aortic stenosis treatment option. Even in very old patients, symptom relief in terminal stage of heart failure after BAV is raising the quality of life. It also gives an opportunity for patients to undergo more technically demanding, and more durable procedures. Heart team has a central role in this decision-making process. ( 1 )