CardioExchange Archive

An 89-year-old woman with severe aortic stenosis is referred to a cardiologist at a major academic center that offers transcatheter aortic valve implantation (TAVI).

A widow for 20 years, the patient lives alone and does well with the assistance of her daughter, who lives nearby. She has two more children in the same town, as well as several grandchildren and great grandchildren. Until five years ago, she worked as a receptionist in the office of her son, who is a dentist.

The patient goes grocery shopping, cooks her own food, is very involved with the local church, and remains socially active. She has never smoked, only drinks socially, has an excellent memory, and reads a book every week.

Her major complaints are angina and shortness of breath on exertion. These symptoms have worsened in the past 2 months, and she had two worrisome episodes of syncope in the past 2 weeks.

Her other medical issues include atrial fibrillation that is rate-controlled, as well as hypothyroidism.

Her exam reveals a blood pressure of 110/70 mm Hg and an irregularly irregular heart rate at 80 bpm. Her venous pressure is normal, and her lungs are clear. A cardiac exam shows no RV lift, but a grade 3/6 crescendo–decrescendo systolic midpeaking murmur, heard throughout the precordium and loudest at the upper sternal border. The aortic-closure sound was audible but diminished. There was no loud pulmonary component, and no diastolic murmurs or gallops were detected. The carotid upstrokes were slightly diminished and delayed, and no separate carotid bruits were audible.

The patient’s abdomen is soft and nontender, with no organomegaly or palpable masses. The distal pulses are 1–2+, and her extremities are warm and well-perfused without edema.

Echocardiography shows a trileaflet aortic valve with decreased mobility; a short-axis planimetry mitral valve area of 0.6 cm²; a peak velocity of 3.8 m/sec, and a mean calculated gradient of 45 mm Hg. The patient has a mildly depressed LV ejection fraction (45%–50%), a nondilated left ventricle, normal RV function, bileaflet mitral valve prolapse with moderate-to-severe mitral regurgitation, and moderate-to-severe tricuspid regurgitation (TR velocity, 3 m/sec).

Cardiac catheterization reveals no obstructive coronary disease. The right-atrial pressure is 8 mm Hg, with a pulmonary-artery pressure of 30/16 mm Hg (mean, 22 mm Hg), and a pulmonary capillary wedge pressure of 13 mm Hg. LV pressure was 190/12 mm Hg, and aortic pressure was 150/65 mm Hg. Cardiac index is calculated at 1.6 L/minute.

Questions:

1. Would you recommend aortic valve replacement? If so, would you favor TAVI or a conventional approach?
2. What other testing would you do to help inform your decision?
3. Should there be an age cutoff for advanced therapies in cardiac disease?

Editor’s Note: For a few hours after initial publication of this post, the values for the patient’s LV pressure and aortic pressure were incorrect. The correct values now appear.

Response:

James Fang, MD

March 9, 2012

This elderly but very independent and functional woman appears to have symptomatic multivalvular heart disease. Exertional dyspnea, angina, and syncope would all be expected, given the severity of her valvular lesions.

Although significant mitral regurgitation is not uncommon in patients with severe aortic stenosis, this patient’s bileaflet prolapse and unremarkable filling pressures suggest that the MR is an independent lesion. The low-normal ejection fraction is particularly worrisome. Although some evidence has shown that mitral regurgitation can improve after aortic valve replacement (Circ Cardiovasc Imaging 2012; 5:36 and Ann Thorac Surg 2007; 83:1279), the nature of this patient’s MR suggests that it will persist and remain symptomatic.

It is interesting that the right-atrial pressure is only 8 mm Hg, with moderate-to-severe tricuspid regurgitation and normal pulmonary-artery pressures. This would imply longstanding primary TR, not secondary to RV dysfunction. The low cardiac index is indicative of the poor forward-stroke volume as a consequence of MR and aortic stenosis.

The patient’s age and multivalvular heart disease increase her operative risk but are by no means prohibitive. The key issue is the nature of the cardiac surgery support at the institution. Many programs have surgeons who are extremely experienced in this area and could therefore handle such a patient with a very reasonable risk for morbidity and mortality.

TAVI’s role continues to evolve but is currently reserved for patients who are at extremely high or prohibitive risk for conventional surgery. It is not clear to me that this patient has that level of risk. A useful approach would be to calculate an STS score or EuroScore.

Therefore, I would recommend aortic valve replacement and mitral valve repair as a primary strategy. TAVI should be undertaken only after disclosing the caveats of this therapy to the patient and her family.

Further testing does not seem necessary to me. Published evidence is insufficient to suggest using BNP level to guide therapy, although some clinicians might be more comfortable with an elevated value.

In general, medicine has no “age cutoffs.” Age is only one of many criteria that clinicians use to decide on a course of therapy for given patient. In the end, the weight of evidence-based medicine is always tempered by an individualized approach and the exercise of judgment.

Follow-Up:

Tariq Ahmad, MD, MPH

March 15, 2012

The patient did, as Dr. Fang recommended, undergo “conventional” aortic valve replacement and mitral valve repair. She had been seen in consultation by the cardiac surgeons at our medical center; they determined that her calculated STS score was within an acceptable range for them to proceed with surgery. The risks and benefits were discussed at length with the patient and her family, who felt that she still had “many good years left” and wanted to proceed. Her surgery was successful, and her postoperative course was uneventful. After discharge, she spent some time in cardiac rehab, where she regained her strength. She was seen in follow-up clinic and had no further episodes of chest pain or shortness of breath on exertion.