Aortic Valve Disease
Patient Presentation:
K.S., a 64 year-old male, presented to the ER with complaints of tightening in the center of his chest as well as lightheadedness. He also reported gradual onset shortness of breath several hours earlier while he was walking outside with his wife, stating he “almost passed out” at that time. The patient stated he had been told by his cardiologist five years ago that he had “some sort of murmur” but it was “nothing of concern.” Upon physical examination, the patient was diaphoretic with biphasic pulses palpated in bilateral carotid arteries and with faint peripheral pulses in upper and lower extremities bilaterally. A harsh, loud, grade V murmur was noted at the second intercostal space right sternal border accompanied by a thrill radiating to the left sternal border. Presence of S4 and left ventricular heave noted. Crackles in bilateral lung bases were also present. No jugular venous distention, hepatomegaly, or peripheral edema was noted.
Differential Diagnoses:
Aortic stenosis, aortic regurgitation and insufficiency, left ventricular hypertrophy, pulmonic stenosis, idiopathic hypertrophic subaortic stenosis, mitral regurgitation, tricuspid regurgitation, mitral stenosis, and tricuspid stenosis were differential diagnoses.
Diagnosis:
BP: 140/110 indicates narrowed pulse pressure
Chest X-ray: reveals left ventricular hypertrophy and calcification of the aortic valve
EKG: R wave in V5 and V6 of 40mm & S wave in V1 and V2 of 35mm
Echocardiogram: ejection fraction of 30%; aortic valve thickening and dilated aortic root
Cardiac catheterization: aortic valve area of 0.7cm² (decreased) and mean pressure gradient of 47mmHg (elevated)
These findings and clinical presentation indicate the diagnosis of severe aortic stenosis and insufficiency with left ventricular hypertrophy.
Treatment:
Immediately after the results of the cardiac catherization, the patient was taken to the OR in order to undergo aortic valve replacement. The procedure was performed with endotracheal intubation and general anesthesia. The surgery was performed with median sternotomy and the use of cardiopulmonary bypass. During the procedure, a transesophageal echocardiogram was performed to confirm the correct functioning of the new tissue valve. Temporary epicardial A-V pacing wires were placed in case of post operative bradycardia or heart block. A Jackson-Pratt drain and a chest tube were placed in order to empty fluids from the chest and pericardium and prevent pneumothorax or hemothorax.
Outcome:
Postoperatively the patient remained intubated and was transferred to the Cardiothoracic Surgical ICU. A safe and uncomplicated extubation was possible 45 minutes post operatively. The JP drain was placed on bulb suction and the chest tube was placed on -20cm wall suction. No air leak or crepitus were noted. The A-V wires were connected to an external pacemaker with the settings VVI at 40, mA of 10, and sensitivity of 0.8mV. The patient had normal sinus rhythm and a heart rate of 70s-80s with no pacing. He was transferred to the cardiothoracic surgical step-down unit after 24 hours where he remained stable. The chest tube was placed on water seal 36 hours postoperatively, as the serosanguineous output dissipated and no air leak was noted. Medical management included daily INR levels to determine dosage of or need for Coumadin®. The patient's vital signs remained stable and Lasix® 20mg po daily was discontinued on post-op day 3 as bilateral lungs remained clear to auscultation. A low dose ACE-inhibitor and beta blocker were given daily. On post-op day 4 the chest tube and JP drain were removed. No complications occurred and the patient was able to be discharged on post-op day 5. Five hours before discharge the patient's temporary A-V wires were removed with the patient in the supine position. Close surveillance of vital signs and cardiac rhythm were done for the next five hours due to the possible complication of cardiac tamponade. No respiratory distress, tachycardia or EKG changes occurred and the patient was discharged home with his wife.
Case created by Kate Sparveri, 2010.