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5yr

87-Year-Old Male with Aortic Stenosis

Roger is 87 and in relatively good health except for progressing heart failure (LVEF 30%). A recent physical exam revealed a low-intensity carotid pulse and an abnormal heart murmur — suggestive of aortic stenosis. An echocardiogram confirmed a calcified aortic valve.

His aortic stenosis could be a factor in his progressive heart failure. Worsening symptoms of aortic stenosis include:

Rapid heart rate or heart palpitations
Feeling faint, dizzy, or actually fainting
Shortness of breath
Fatigue
Angina or feelings of tightness or pressure
Complications of worsening aortic stenosis are serious:

Exacerbation of heart failure
Stroke
Blood clots
Dangerous heart arrhythmias
Risk of infection affecting the heart, including endocarditis
He is rather frail but has no signs of additional organ dysfunction and is concerned that he is inoperable. An angiogram showed his iliac and coronary arteries are open and unobstructed. His kidney and pulmonary function are good.

Given his fragility, would a conservative approach using an ACE inhibitor or beta-blocker be the most appropriate treatment?

Is Roger a good candidate for transcatheter aortic valve replacement (TAVR)?

  • 5yr
    Need to know how severe his AS is for sure. Echo should be more informative. What are his BP, HR, rhythm, peak velocity and mean gradient across the AV, was dobutamine echo done in case gradient was low “low flow low gradient”?
    It’s hard to prescribe these meds before knowing the above.
  • 5yr
    Patient has sig. Heart failure and Low LVEF. If his Aortic stenosis is determined to be severe by Echo and hemodynamics, TAVR should be considered. His Life expectancy is more than 1 year given he does not have other significant co morbidities. TAVR should be offered but first all hemodynamics to determine severity of his Aortic stenosis in face of low VEF and Contractile reserve function should be assessed.
  • 5yr
    In the modern era, I'm not sure that fragility should preclude appropriate treatment (unless the patient is hospice bound). That said, there's not enough information above to answer the question - how severe is the AS? What's his BNP? Per the 2020 ACC/AHA valve guidelines ( asymptomatic severe AS with an EF under 50 is a class 1 indication for AVR. So, regardless of symptomatology, I would offer SAVR vs. TAVR (likely TAVR given the story) with initiation of medical therapies for CHF concomitantly.
    • www.jacc.org

    www.jacc.org

    Source : https://www.jacc.org/doi/10.1016/j.jacc.2020.11.018?_ga=2.123142670.486894932.1619361371-251651954.1618017165

  • 5yr
    A simple Valvular Calcium Score can determine the severity of the aortic stenosis and guide the direction of therapy towards medical versus TAVR.
  • 5yr
    First inquiry is severity of his aortic stenosis
    Given decreased ejection fraction his gradient is likely not to be very high “ low flow low gradient but careful echo evaluation by continuity equation and planimetry if valve by 3 d echo should give a good idea of the severity of the AS. If not a dobutamine stress test may be useful. If AS
    Severe ( or moderately severe)
    ( valve are less than 1 or perhaps slightly higher
    Then would proceed to Cath to help determine is low ef due to
    significant CAD
    If yes TAVR probably not indicated
    If yes would proceed to TAVR
  • 5yr
    First I think there needs to be a careful assessment of the valve. Diagnosis of severe aortic stenosis is much more challenging with a depressed ejection fraction but not at all outside the scope of general cardiology practice with fairly well-laid-out guidelines for the use of echo with or without dobutamine, MRI, valvular CT, etc. Cardiac catheterization of course is vital as the coexistence of severe CAD would be very pertinent and the valve can be assessed this way as well. This patient fortunately does not have that problem.

    I personally would not want to begin vasodilator therapy without knowing if aortic stenosis were severe or not. If AS is indeed severe, this patient would almost certainly be offered TAVR at my center.

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