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5yr

TAVR Treatment Quandaries: What Would You Do?

A fifty-three-year-old male with aortic stenosis presents for cardiothoracic surgical consultation. He reports that he has had increased shortness of breath and soreness in his chest, but he suspected he was tired; he reports that his office called an ambulance after he fainted at work. Patient denies significant medical history as well as any history of alcohol or tobacco consumption. He does take aripiprazole and fluoxetine daily, and reports a history with depression. The patient is married and lives with his wife. Of note, the patient's wife claims that he smokes and drinks, and that he has intermittent episodes of jaundice but refuses to seek medical treatment for it. The patient is very upset by these claims, and has asked his wife to leave the room.

What type of surgical procedure would you recommend for the patient's aortic stenosis?

How would you handle the inconsistencies in the patient's medical history?

  • 5yr
    There's a lot of missing information here. How severe is the aortic stenosis? What is the ejection fraction? Has there been a cath to rule out epicardial CAD? BP? Diabetes? Basic labwork?

    As to inconsistencies in the patient's history, I don't mind if he is 'upset' or wants to speak to me alone, but if he doesn't want to tell me the truth then I can't really accept him putting his life in my hands. I think there has to be a good doctor:patient relationship first and foremost. To get there, spend the time taking a good history, after which there will be more information to go by.
  • 5yr
    I would obtain a transthoracic echo, abdominal ultrasound and/or CT scan, and LFTs. I would have a seriou discussion with the patient about his alcohol consumption prior to deciding on whether the patient should proceed with SAVR with possible mechanical AVR and lifelong Coumadin versus bioprosthetic AVR versus TAVR.
  • 5yr
    I agree with T Passo that further data is required. Would not start invasively (heart cath), but rather with non-invasive evaluation by transthoracic echocardiography. The report does not indicate that he has severe stenosis and it is unclear whether the fainting episode was even exertional. I have seen multiple patients referred with fainting in the setting of less than severe AS and they almost invariably have alternative pathology. He certainly needs extensive prior workup and it's surprising that he's at the point of seeking CTS consultation. HIs response to the wife's mention of drinking and jaundice may well be the A of a CAGE. In direct response to the question - I would recommend no surgical (or, indeed, transcatheter) procedure at this stage.
  • 5yr
    I need quantitative data prior to theraputic decision
  • 5yr
    full heart cath, CT abdomen,event monitor,cmp

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