Case Studies

Case 3: Diseased heart valve

You are the house officer on the acute medical unit. Overnight an 83-year-old woman has been admitted with chest pain and shortness of breath. On the post-take ward round, the senior house officer on-call that night presents the patient to the consultant. The woman had been feeling unwell and had experienced central chest pain, which was non-radiating. She was short of breath, nauseous, sweaty and clammy. Her past medical history is significant for a coronary artery bypass graft (CABG) in 1989, several non-ST segment elevation myocardial infarctions, atrial fibrillation (AF) and hypertension. Admission bloods were all within normal ranges. Her ECG shows T wave inversion in leads I, aVL and V3–V6 and her chest X-ray shows a raised right hemi-diaphragm and sternotomy wires consistent with her previous CABG. Her blood pressure is 160/90 mmHg. On examination she is comfortable at rest, her pulse is 83 regular, her JVP is not elevated but the character of her carotid pulse is slow-rising. Auscultation of her heart sounds reveals a very quiet second sound and an ejection systolic murmur heard shortly after the first heart sound which is loudest in the second intercostal space in the right upper sternal border and which radiates to both carotids.

• 1.What is the most likely diagnosis in this woman?

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  This woman’s presentation with this cardiac murmur is most in keeping with aortic stenosis (AS). The classic triad as-sociated with AS is dizziness (presyncope), dyspnoea and chest pain; this woman has two of these. Patients who present with dyspnoea (as opposed to others of the triad) have the poorest prognosis because dyspnoea often indi-cates an already failing left ventricle. The most common cause of AS is senile calcification of the aortic valve, which generally occurs after the age of 70, although in patients with a congenital bicuspid valve the onset is earlier.

• 2.Why does she have a soft second heart sound?

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  This woman’s second heart sound is soft because of the poor mobility of the cusps of her aortic valve – her calcified heart valves both open and close poorly.

• 3. Which investigation would you like to do next?

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  This woman underwent an echocardiogram to assess the degree of stenosis, and corresponding function of her left ventricle. The echo report revealed a heavily calcified, restricted aortic valve with an aortic valve area of 0.4 cm₂. A valve area of less than 0.8 cm₂ is considered to be severe AS.

• 4.How would you treat this woman?

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  The only definitive treatment of AS is replacement of the diseased valve. Without valve replacement, survival is less than 3 years. This woman is on the waiting list for a transcatheter aortic valve implantation (TAVI), an alternative treatment to conventional surgical valve replacement. Catheter access to the aortic valve is achieved via the femoral artery or vein, or surgically via a mini-thoracotomy. A replacement valve is inserted through the catheter and placed over the diseased valve, resulting in its obliteration. TAVI is considered in patients who are too high risk for conven-tional surgery.