Left Ventricular Dysfunction and Aortic Stenosis
Short Summary

62-year-old female with systolic heart murmur for 6 years. Her first echocardiogram showed mild to moderate LV dysfunction with regional wall motion abnormality. The second echocardiogram the left ventricular function was interpreted as normal, there was left ventricular hypertrophy and severe aortic stenosis. The expert recommends to perform another third echocardiogram. If the patient has truly left ventricular function and severs aortic stenosis then aortic valve replacement surgery is recommended, even if she is asymptomatic. If the LV function is good than she could be followed up every 6 month and perform surgery only when she became symptomatic.

Patient's Questions Medical Background

This is a 62 years old woman with a history of hypercholesterolinemia treated by statines . Otherwise healthy.
She is known to have systolic heart murmur for 6 years. She is completely asymptomatic.
She performed 2 echocardiographic exams on the same date (07/2008) with contradiction results.
On the first echocardiogram there was mild to moderate LV dysfunction (EF 42%) with regional wall motion abnormality (dyskinesia of the septum and hypokinesia of the anterior wall and apex, no LVH and sever aortic stenosis (AS) based on aortic valve area of 0.5 cm² and high trans-valvular gradients 74/52 mmHg.
On the second echocardiogram the left ventricular function was interpreted as normal, there was left ventricular hypertrophy and severe aortic stenosis based on mean trans valvular gradients of 64 mmHg. Valve area was not calculated.
Coronary angiography reveal no obstructive lesions, normal left ventricular function and transaortic peak to peak gradient of 30 mmHg which is correspond to moderate aortic stenosis.

Expert's Opinion

Recommendations:
  1. This patient must perform another third echocardiogram in a well established experienced echo lab preferably in a university hospital because the discrepancies between the 2 echocardiograms are significant and making no sense.
  2. If the patient has truly left ventricular function and severs aortic stenosis than according to the guidelines she needs surgery (to replace the valve ) even if she is asymptomatic. If the LV function is good than she could be followed up every 6 month and perform surgery only when she became symptomatic.
  3. The left ventricular angiogram which reveal normal LV function support the second echo results but as I mention previously I would trust another echocardiogram in a good experienced echo lab. It might be that the patient has LBBB which my explain the abnormal septal and apical walls motion .
  4.  Regarding the severity of the aortic stenosis – according the data presented to me I think she has probably severe aortic stenosis as shown by the 2 echo exams. In my experience a peak to peak aortic transvalvular gradient of 30 mmHg during angiography is corresponded to moderate to severe AS (not mild) and is depend also on cardiac output and blood pressure during measurements. There is also a phenomenon called low flow severe aortic stenosis this woman might have.
  5. I would suggest doing a stress test like ergometry or preferably exercise echo in order to see her exercise capacity and whether she is truly asymptomatic and also looking if her blood pressure rise normally during exercise. According to guidelines if the blood pressure is drop during exercise or she develops symptoms during exercise than this is an indication for surgery in a patient with severe aortic stenosis.
  6. Regarding prognosis: I think this lady will need sometime (not in the far future) aortic valve replacement but her prognosis after timely successful surgery is very good almost like those without valve disease
 
In conclusion: The key point in this case regarding indication for surgery is whether this lady has left ventricular dysfunction and whether she is truly asymptomatic, Therefore she needs exercise test and a good echocardiogram. If she is truly asymptomatic and her LV function is good watchful closed follow up by repeat echocardiogram every 6 month is recommended. If the LV function is abnormal or she is symptomatic than aortic valve replacement surgery is recommended.
There is no medical therapy for aortic stenosis. Statins therapy which she is currently getting may slow down the progression of the disease although this was not proved scientifically.

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