Case 1
March 2016 59 yr. old male, newspaper writer, with worsening dyspnea /orthopnea past few months PMH diabetes, celiac disease Reports chest discomfort, positional coughing and pedal edema last 10 days ED admission: found hyperkalemic (6mEq/L); worsening SOB, anxiety PEA arrest 5 min after Lorazepam administration Resuscitated; admitted to CCU
Transthoracic Echocardiogram Mar 2016 BP 130/40 mmhg Height 5 11 Weight 167 lb
BP 130/40 mmhg Height 5 11 Weight 167 lb
Cardiac Catheterization Coronaries: 100% mid LAD, 100% OM1, 80% RCA Hemodynamics: LV 120/16; PCW 20mmHg, PA 62/24 mmhg, RA15mmHg, CI 1.7L/min/m²
Myocardial Perfusion Scan Abnormal, consistent with moderate anteroapical, mild apical and septal, and mild to moderate inferolateral viability. Mild to moderate anteroseptal and mild inferoposterior scarring LVEF 22%
Summary 59-year-old male with progressive dyspnea and orthopnea presents to ER with acute CHF symptoms and PEA arrest Imaging: Moderate-severe AI, mild MR, mild TR (RVSP 44mmHg) LVEDD 7.5 cm, LVESD 6.2 cm, LA 4.5cm, LVEF 21% Sub-total LV hypokinesia (basal segments hypokinetic) Moderate RV dilatation, moderate-severe RV dysfunction. 3 Vessel CAD
Management Hypothermic protocol, extubated Commenced aggressive diuresis Medical therapy for CAD HF therapy: carvedilol, Lisinopril, Digoxin, Spironolactone Endocrine + Nutritional optimization (noted T2DM, protein deficit) CT Surgery consult
M 59y: 1 st presentation of ischemic/valvular cardiomyopathy; severe AI What would you recommend? 1. Continue medical therapy + follow-up in 4 weeks 2. CABG + AVR 3. Refer for LVAD 4. PCI then follow-up in 4 weeks
Plan of Care Presented with operative risk, patient opted to defer surgery and try medical therapy first Continue diuresis, neurohormonal inhibitors (entresto) Nutritional, metabolic, and endocrine optimization Follow up with HF, Cardiology and CVS as outpatient
March to October 2016 Doing well Asymptomatic. Walks 5 miles daily Writing weekly articles for NY Times On GDMT for HF
6 Month Follow-Up Cardiology Visit. October 2016 Continues to do well NYHA class I Wishes to continue current plan of medical therapy Declined AICD Follow up in 4 months with exercise stress-test
Stress Echocardiogram Feb 2017 5min 01sec; 4 METS (70-84% pred peak HR) Terminated for dyspnea ST elevation anterior/septal segments; transient ischemic LV dilatation Severe PHTN at peak (RVSP 86mmHg Vs 40mmHg at rest)
February 2017 Admitted post-stress test Cardiac catheterization: Coronaries unchanged. Hemodynamics LV 120/16 mmhg, Ao 120/50 mmhg, PCW 12 mmhg, PA 35/15 mmhg, RA 6 mmhg, CI 2.5 l/min/m 2 Echocardiogram Severe AI, LVEF 25%, LVEDD 7.5 cm, Moderate RV dysfunction
Summary 60 y male with asymptomatic ischemic cardiomyopathy, severe aortic regurgitation and severe LV systolic dysfunction re-presents with positive stress test.
What would you recommend? 1. Continue medical therapy 2. CABG + AVR 3. PCI + TAVR 4. Refer for transplantation 5. Further testing
Patient opts for surgery which valve? 1. Biological 2. Mechanical
March 2016 AVR: 25mm St Jude Trifecta Bovine Pericardial Valve CABG x 4: LIMA to LAD; LIMA to D1; Radial Artery to OM1; SVG to PDA Uneventful recovery, discharged home on POD 7
Discharge Transthoracic Echocardiogram BP 119/69 mmhg Height 72in Weight 173 lb
Absent AR, trace MR, mild TR (RVSP 30mmHg) LVEDD 5.5cm, LVESD 4.7cm, EF 33%
4-month F/U Transthoracic Echocardiogram BP 119/69 mmhg Height 72in Weight 173 lb
Mar 2016:Baseline EF 21% Jul 2017: Postop EF 38%
Case 2 26 year old male with remote history of heart murmur Progressive dyspnea on mild exertion past few months Referred for cardiology consult by PCP
Transthoracic Echocardiogram Aug 2017 BP 130/40 mmhg Height 5 11 Weight 167 lb
Summary Previously asymptomatic 26-year-old male with known heart murmur develops dyspnea on mild exertion Initial TTE report: Severe AS (AVA 0.7cm², mean PG 75 mmhg), severe AR, complex AV calcification involving the AMVL, mild MR, mild TR concentric LVH (LVPWd 1.7cm, IVSd 1.6cm) LVEDD 5.9cm, LVESD 3.6cm, LA 4.5cm, EF 55-60%
What would you recommend? 1. Active surveillance, repeat TTE in 3 months 2. Aortic valve replacement - mechanical 3. Aortic valve replacement - biological 4. TAVR 5. Ross
Management All AVR options were discussed in detail Patient felt strongly against anticoagulation Opted for Ross procedure Underwent Ross operation. Doing well 3 weeks post-op