AAAAA
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68 year old asymptomatic man found to have aortic
stenosis on echocardiogram with mean transvalvular
gradient at 68 mm Hg.
What is the next step of management ?
1. Observation (watchful observation)
2. recommend aortic valve replacement
3. Percutaneous ballon valvuplasty
4. Medical therapy
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| Jinx
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valve replacement?
sounds like severe stenosis
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| AAAAA
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Dr. Jinx,
How do you define severe aortic stenosis ?
What is the gradient has to do with valvular
replacement and how the gradient affects your
management ?
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| jvo_md
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I'll go with 3. Percutaneous ballon valvuplasty
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| Jinx
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Mild aortic stenosis with an aortic valvular gradient below 25mm Hg.
Moderate aortic stenosis with a valvular aortic gradient between 25 and 60 mm Hg.
Severe with an aortic valve gradient over 65 mm Hg.
Critical aortic stenosis with an aortic valvular gradient over 100 mm Hg
Percutaneous balloon aortic valvotomy has an important role in treating adolescents and young adults with AS but a very limited role in older adults.
There is no perfect method for weighing all of the relevant factors and identifying specifically high- and low-risk elderly patients The decision to proceed with valve replacement depends on an imprecise analysis that considers the balance between the potential for improved symptoms and survival and the morbidity and mortality of surgery.
In the vast majority of adults, AVR is the only effective treatment for severe AS
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| AAAAA
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I have wrestled with this question for long time and appreciate all your input.
On one hand, all asymptomatic patients with AS do NOT require any intervention.
Once a pt develops chest pain, congestive heart failure, sycope, aortic replacement and cardiac cath. is waranted.
Percutanous aortic vulvaplasty has absolutely no role in managment of adult AS but do have a role in mitral stenosis.
In the old days in 1940's-1950's, surgeons basically open the chest and "jam" a finger through the muscle wall of the left heart muscle to forcefully "jam" open the mitral valve without cutting open the heart (there were no heart-lung bypass machine at that time)
So the official answer is watchful observation.
You DO not do anything if the patient is asymptomatic despite the gradient is 68 mmHg.
Any feedback is welcome !
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| AAAAA
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The secrets of answering USMLE are:
asymptomatic. You don't go around and
operate on anyone that is asymptomatic !
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| achilles
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just to add to what jinx said.
surgery is usually advised when the valve area is below 0.8cm2 ( normal is between 2.5 - 3 cm2) and when the patient is symptomatic(ref-kaplan).
balloon valvuloplasty is indicated in patients who are too ill to tolerate surgery.
thats good info jinx. whats the source.
and thanks for the answer to the confusion about bone scan or MRI in osteomyelitis. good going jinx !
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| achilles
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the only thing though is that this patient is aymptomatic. AAAAA, would'nt the patient have symptoms if he has severe AS.
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| achilles
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opps, you already said that. it just happened that we were posting at the same times AAAAA.
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| AAAAA
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Dr. Archilles,
Once again, we must be very
careful about the surface area of
the aortic valve.
Please notice an aortic valve area
of 0.45 cm2/m2 is considered
severe.
You must take into account of the
body surface.
An elderly woman who is 5 feet and weighs 100 pds can have a mild
aortic stenosis with 0.8 cm2.
The normal aortic valve is 3-4 cm2
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| achilles
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so the answer is 1-watchful observation.
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| achilles
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that's true AAAAA. body surface area will also matter.
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| AAAAA
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The trick of the question is we must not look at disease at the end-point but a series progressive events.
It may take a pt 10-20 years to develop symptoms.
Before symptoms can develop, the myocardial cells
have to re-model itself to undergo hypertrophy !
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| AAAAA
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Aortic stenosis has a very long latent period in
which stenosis gradually worsens without
symptoms or an adverse prognosis.
So many patients have echocardiograms
nowadays, you don't call the surgeons
to replace the aortic valves on everyone.
ALL PATIENTS DIE 'WITH' AORTIC STENOSIS,
SOME MILD, SOME MODERATE.
WHAT THE QUESTION REALLY WANT US TO
UNDERSTAND MEDICINE IS WHEN DO WE
INTERVENE ? WE ONLY INTERVENE IF
SYMPTOMS OCCUR : chest pain, angina, heart
failure, syncope.
Otherwise, we are going to replace every man
and woman who are over 75-80 years old with
a mechanial aortic valve !
Who is going to pay for these operation ?
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| Jinx
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thanx for the encouragement achilles!
i think ur an integral part of this forum and do a really great job--keep it up!!
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| AAAAA
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The saline point of this question is :
For aortic or mitral stenosis, you usually wait
until symptoms occur before valvular replace-
ment.
But for aortic or mitral regurgitation, you DO
NOT wait for symptoms and go ahead for
replacement.
Stenosis----watchful waiting
Reguritation---operate once you make the diagnosis
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| Jinx
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good point AAAAA
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