Title
:
Does this patient need Transcatheter Aortic Valve Replacement or Medical Therapy? Challenges in decision making for patients with concomitant Aortic Stenosis and Heart Failure with Preserved Ejection Fraction.
Introduction
:
Patients with low flow low gradient (LFLG) severe aortic stenosis (AS) with preserved ejection fraction (EF) often provide diagnostic challenge in optimal patient evaluation and clinical judgement is required in determining contribution of AS towards symptomatology. Limited clinical outcomes data exist to guide clinical decision making. We present a clinical case where invasive hemodynamics with vasodilator challenge was utilized in determination of optimal management strategy.
Clinical Case:
84-year-old male with hypertension, chronic heart failure with preserved EF, chronic obstructive pulmonary disease, chronic kidney disease, prior stroke, chronic atrial fibrillation on anticoagulation, moderate to severe AS was referred to structural heart and valve clinic for progressive functional decline with NYHA Class III symptoms over 6 to 8 months for transcatheter aortic valve replacement (TAVR). Echocardiogram demonstrated LFLG moderate to severe AS with normal EF, mean aortic valve (AV) gradient 26 mmhg, aortic valve area (AVA) 0.9 cm2, dimensionless index (DI) 0.26, stroke volume index (SVI) 30 ml/m2, small left ventricular cavity with moderate left ventricular hypertrophy. Patient has uncontrolled hypertension with systolic blood pressure (SBP) ranging 190-200 mmHg on multiple antihypertensive medications. Differential diagnosis included severe LFLG aortic stenosis with preserved ejection fraction, progressive heart failure with preserved EF and severe systemic hypertension. Coronary angiography demonstrated non obstructive disease. Invasive hemodynamics recording at rest and after nitroprusside infusion with peak dose of 2.5 mcg/kg/min in incremental doses over 10 minutes demonstrated significant afterload mismatch and unmasked underlying severe LFLG aortic stenosis with preserved EF contributing to recent clinical decline (Rest: mean AV gradient 22 mmhg, AVA 0.84 cm2, EF 55%, SVI 28 ml/m2 using thermodilution cardiac output (CO) of 5.3 l/min, SBP 210/100 mmHg, heart rate 84 beats per minute; After nitroprusside infusion: mean AV gradient 42 mmhg, AVA 0.9 cm2, SVI 34 using thermodilution CO of 7 l/min, SBP 110/80 mmHg, heart rate 90 beats per minute). Patient underwent successful TAVR via transfemoral approach with 26 mm Sapien 3 valve with good results. There was significant improvement in clinical symptoms and functional class.
Discussion
:
Left ventricular afterload and filling pressure reduction with nitroprusside infusion is an important part of evaluation in patients with LFLG severe AS with preserved EF especially in the presence of severe systemic hypertension. It can confirm severe AS or help reclassify severe AS to moderate AS and uncover heart failure with preserved ejection fraction as major contributing factor towards symptoms.