A 50 year old man with aortic stenosis is doing exercise for 11 minutes according to bruce protocol. Exercise had to be stopped due to fatigue. Peak pressure gradient is 60mmHg between the two sides of the aortic valve. What is the best management?
B. Aortic valve replacement
C. Balloon aortic valvuloplasty
D. Medical follow up
Correct answer : D. Medical follow up
Surgery is done only for severe aortic stenosis. For diagnosis of severe aortic stenosis, the peak gradient should be more than 60mm Hg (as per Feigenbaum’s Echocardiography) / more than 64mm Hg (as per CMDT 2011).
Defining severity of aortic stenosis using echocardiography
68 U/L 45 U/L 3.5 mg/dL 3.5 mg/dL Mean gradient (mm Hg) 0 <25 25-40 >40 Peak gradient (mm Hg) 0 <35 35-60 >60 Valve area (cm2) 3.0-4.0 1.6-3.0 1.0-1.5 <1.0
Ref: Feigenbaum’s Echocardiography 7th, p276
Operation is indicated in patients with severe AS (valve area <1 cm2 or 0.6 cm2/m2 body surface area) who are symptomatic, those who exhibit LV dysfunction (EF <50%), as well as those with BAV disease and an aneurysmal or expanding aortic root (maximal dimension >4.5 cm or annual increase in size >0.5 cm/year), even if they are asymptomatic. Patients with asymptomatic moderate or severe AS who are referred for CABG surgery should also have AVR.
Ref: Harrison. 18th
Indications for aortic valve replacement include symptoms and a mean gradient by echo/Doppler of > 40 mm Hg or peak instantaneous gradient of > 64 mm Hg.
Ref: CMDT 2011
Use of cardiac cauterization in aortic stenosis
Right and left heart catheterization for invasive assessment of AS is now performed infrequently but can be useful when there is a discrepancy between the clinical and Doppler echocardiographic findings. Appropriate concerns have been raised that attempts to cross the aortic valve for measurement of left ventricular pressures are associated with a risk of cerebral embolization. Catheterization is also useful in three distinct categories of patients: (1) patients with multivalvular disease, in whom the role played by each valvular deformity should be defined to aid in the planning of operative treatment; (2) young, asymptomatic patients with noncalcific congenital AS, to define the severity of obstruction to LV outflow, since operation or percutaneous aortic balloon valvoplasty (PABV) may be indicated in these patients if severe AS is present, even in the absence of symptoms; balloon valvotomy may follow left heart catheterization in the same sitting; and (3) patients in whom it is suspected that the obstruction to LV outflow may not be at the level of the aortic valve but rather at the sub- or supravalvular level.
Ref: Harrison 18th