Aortic stenosis

Zakaria Salam Alagha
MSc Cardiology

Outline
• Etiology
• Pathophysiology
• Clinical presentation
• Work-up
• Step by step treatment algorithm
• Follow-up
• Management in special populations

Supravalvular
• Williams syndrome
• Congenital
anomalies of aorta
• Familial hyper-
cholstrolemia
Valvular
• Calcific aortic
stenosis
• Atherosclerosis
• Rheumatic
• Strept
• Commisural
fusion
• BAV
• 0.5-2%
• AS/ AR
• AD
• AD 5-9X
• IE 10-30%
• Other
pathologies
Subvalvular 10%
• Fibromuscular
membrane
• Recurrence
• Shone syndrome.

Age-related etiology
?!Aortic
sclerosis
Rheumatic
BAV
Senile
calcification
CTD Radiotherapy
Lipid ++ DM/HTN/smoking
CKD

13- A 40-year-old male with a history of bicuspid aortic valve (BAV)
presents to your office with complaints of exertional dyspnea. He
recently joined a gym to help him lose weight. He has started jogging
on a treadmill, however he notes shortness of breath when running at
an incline. He denies chest pain and is able to run on level ground
without difficulty. His physical exam includes a height of 70 inches,
weight of 225 lbs, blood pressure of 112/73 mm Hg, and a heart rate
of 82 bpm. His carotid pulses are prominent and lungs are clear. His
heart exam is notable for a holodiastolic murmur. There is no lower
extremity edema. A transthoracic echocardiogram is performed. His
left ventricular ejection fraction is 60%. There is a BAV with moderate
aortic regurgiation. His ascending aorta measures 4.8 cm. These
findings are similar to his echocardiogram performed last year.
What is the next best step in the management of this patient?
• A. Genetic testing.
• B. Echocardiogram in 6 months.
• C. Cardiac surgery referral.
• D. Hydralazine 10 mg three times a day.
• E. Computed tomography scan in 12 months.

Screen 1st
degree
relatives
Scan entire
aorta BB
Isometric
excrcise with
high static load
Diltation
Aneurysm
Dissection
AoC
VSD
AS- sub or
supra valvular

• AS  Pressure overload
• Compensatory LVH (++ sacromeres)
• Normalize wall stress
• LV cavity remains normal
• LV EF remains normal
• End stage
𝑊𝑎𝑙𝑙 𝑆𝑡𝑟𝑒𝑠𝑠 =
𝑃𝑟𝑒𝑠𝑠𝑢𝑟𝑒 × 𝑟𝑎𝑑𝑖𝑢𝑠
2 𝑤𝑎𝑙𝑙 𝑡ℎ𝑖𝑐𝑘𝑛𝑒𝑠𝑠

Clinical Picture
Dyspnea 60%
•Small non-
compliant
ventricle
•Passive filling
↓↓ → DD
•Atrial
contraction
maintains
preload.
•Systolic
dysfunction
Chest pain
50%
•Supply demand
mismatch
•Prolonged
systole→ ↓
diastolic
perfusion time
•Associated CAD
Syncope 40%
•Fixed
Obstruction
•High LVP→
Vasodepression
•Peripheral VD
•Arrhythmias
•SCD
Cerebral
embolization
Turbulance
across
stenotic AV
•Acquired vWD
•Chronic GI
bleeding
•Epistaxis
•Bruising

3-A 30-year-old male is referred for evaluation of a murmur. He reports
no symptoms and has no significant medical history. On physical
examination his height is 69 inches and weight is 185 lbs. His blood
pressure is 135/70 mm Hg with a regular heart rate of 78 bpm. His lungs
are clear. Prominent carotid pulsations are present. The jugular venous
pulse is at the level of the sternal notch. The apical impulse is slightly
enlarged and laterally displaced to the anterior axillary line. The S1 and
S2 are normal, and an S3 is present. There is an early systolic click that
does not change with inspiration. Both a soft (grade 2/6) crescendo-
decrescendo systolic murmur and a soft (grade 2/4) decrescendo
diastolic murmur are present along the left sternal border.
• Which of the following is the most likely valvular abnormality in this
patient?
• A. Bicuspid aortic valve with regurgitation.
• B. Patent ductus arteriosus.
• C. Pulmonic valve stenosis with regurgitation.
• D. Rheumatic mitral stenosis and regurgitation.
• E. Degenerative aortic valve stenosis with regurgitation.

57- A 74-year-old female with a history of hypertension and
moderate aortic stenosis (AS) presents to your outpatient
clinic for a routine follow-up evaluation. She reports
worsening fatigue and dyspnea, but no chest pain,
palpitations, presyncope, or syncope. Her blood pressure is
112/80 mm Hg and heart rate is 66 bpm. Her last
echocardiogram, 1 year prior, demonstrated normal
biventricular function, mild mitral regurgitation, and aortic
peak velocity 3.1 m/sec with a calculated aortic valve area 1.3
cm2.
What physical examination finding would suggest progression
of this patient's aortic stenosis?
• A. Increased opening snap-S2 interval.
• B. Ejection click.
• C. Widened splitting of S2.
• D. Enhanced A2.
• E. Late-peaking murmur.

• Parvus et tardus
• LVH
• Aortic thrill
General
• Soft A2 (- - intensity )
• Paradoxical splitting
Sounds
• S4
Additional
sounds
• Late peaking
• Longer duration
• Loudness (>20mmHg)
• Harshness
Murmur
Squatting
Post long
diastole
30 s
post
nitrate

Which of the following CXRs is NOT
classically seen in EARLY AS ?

CXR in AS
• Post-stenotic
dilatation of
ascending aorta
• Aortic calcification
• Cardiomegaly if
concomitant AR or
late.
• LA is markedly
enlarged if
concomitant MVD.

ECG
• The ECG is abnormal in >90% of patients with AS, with
the most common abnormality being left ventricular
hypertrophy (LVH) due to pressure overload.
• The absence of LVH does not exclude severe AS.
• Evidence of LVH and absent Q waves helps distinguish
AS from other conditions such as aortic sclerosis with
IHD.
• AF is uncommon and late finding. It’s presence in
patients without end stage disease suggest co-existing
MVD.
• Patients with AS can often have conduction disease
manifesting as atrioventricular block, hemiblock, or
bundle branch block.( Calcium extention)

A 67-year-old man is presents after incidental finding of a
systolic murmur. He is normally fit, well and active. His
past medical history includes hypertension, gout and
appendectomy. Observations are normal and a TTE
demonstrates severe aortic stenosis. The LV EF is 64%. He
denies any exertional symptoms including shortness of
breath and chest pain.
What is the most appropriate management plan?
A.Review in six months
B.Exercise test
C.Transcatheter aortic valve implantation (TAVI)
D.Aortic valve replacement
E.Trans-oesophageal echocardiogram

Do we need to perform stress ECG?
• Indications ?
– Patient:
• Asymptomatic
• Physically active
– LVEF : Normal
– Severe AS
• Positive exercise test ?
– Development of symptoms related to AS (I)
– Drop of BP below baseline (Iia)

35- A 58-year-old female presents to your office with a 6-
month history of palpitations and dyspnea on exertion.
She has no medical problems and takes no medications.
Her examination reveals a body mass index of 30 kg/m2,
a heart rate of 68 bpm, and a blood pressure 160/80 mm
Hg. Her jugular venous pressure is 6 cm H20. Her cardiac
exam reveals a systolic murmur with a single component
S2.
• What test is most likely to elucidate the diagnosis?
• A. Injection of agitated saline contrast.
• B. Chest X-ray.
• C. Electrocardiogram.
• D. Doppler tricuspid regurgitation velocity.
• E. Doppler aortic velocity across the aortic valve.

• Angle ѳ
– cos 90= 0
– cos 0 = 1
• A wider angle will result in
a greater reduction in
measured velocity
compared to true velocity.
• Angle should be zero =
Parallel
‫من‬ ‫أقل‬ ‫يبقى‬ ‫ممكن‬
‫الحقيقة‬

• We can’t overestimate the gradient
• Except :
– High flow status ;e.g. anemia
– Subvalvular stenosis
• Bernoulli equation ‫الطاقة‬ ‫حفظ‬ ‫قانون‬

• 70 years old male patient, underwent CABG
post extensive anterior MI 5 years ago , after
asymptomatic period, he presents with NYHA III
CHF. Examination revealed Grade 3 Late peaking
SEM, single S2(A2), diminished delayed carotid
upstroke. TTE done

39-An 88-year-old female presents to clinic for progressive dyspnea on
exertion and lower extremity edema. Her past history includes osteoarthritis
and hypertension. She takes aspirin 81 mg daily, metoprolol succinate 25 mg
daily, amlodipine 5 mg daily, and naproxen as needed. On exam, her blood
pressure is 130/60 mm Hg, pulse is 70 bpm, and respirations are 16 breaths
per minute. Her jugular venous pressure is 10 cm H20. There are bibasilar
crackles. She has a late-peaking, harsh systolic murmur along the right upper
sternal border with a single S2. There is 2+ bilateral lower extremity edema.
Her echocardiogram shows a severely calcified aortic valve with reduced
leaflet excursion. Peak velocity across the valve is 3.3 m/sec with a mean
gradient of 28 mm Hg. The calculated valve area was 0.8 cm2 and
dimensionless index is 0.22. The left ventricle (LV) is mildly dilated with a left
ventricular ejection fraction (LVEF) of 25-30% and global hypokinesis.
• Which of the following is the most appropriate next step in the
management of this patient?
• A. Exercise myocardial perfusion scan.
• B. Right and left heart catheterization.
• C. Cardiac magnetic resonance imaging.
• D. Transesophageal echocardiography.
• E. Dobutamine stress echocardiography.

Is this a true stenosis ?
If we increase the flow,
does the AVA increases ?!

 When to use it ?
◦ Low flow, low gradient severe AS
◦ AVA< 1.0
◦ LVEF < 50%
 Why to use it ?
◦ Differentiate true from pseudo severe AS
◦ Determine the presence of contractile reserve.
 Interpretation
◦ If stroke volume ↑↑ >20% contractile reserve
◦ Positive test : Vmax>4.0 m/sec with valve area of
1.0 cm2 at any point during the test protocol.
◦ ↑ AVA to >1.0 cm2 with flow normaliz. pseudo- severe AS.

SV & LVEF Gradient AVA Implications
↑ ↑ - True severe AS
↑ - ↑ Pseudo-severe
AS
- - - Severe CM/
?severe AS

• 136 pt, AVA 0.7, MG 29  LV contractile reserve by DSE
• Present in 92 (Group I)
• Absent in 44 ( Group II)
Monin et al- Circulation 2003; 108:319-24

◦ Patients with pseudo-stenosis do NOT have severe
AS and should NOT be referred for surgical valve
replacement.
◦ IF truly severe  AVR  LVEF ↑↑ by 10 LVEF units or
even to normal (afterload mismatch was the cause of LV
dysfunction)
◦ The presence of contractile reserve suggests a
better prognosis and lower surgical risk with
surgical valve replacement.
◦ IF patients with NO contractile reserve survive, EF
improves and outcome is good. (Intervention;IIa)
◦ If there is NO contractile reserve
 Assess calcium score by CT to determine AS severity

Low gradient (<40 mmHg)
+
Small AVA ( < 1.0 cm2)
Flow
Low flow
LOW LVEF NORMAL LVEF
Normal flow
Is this a true stenosis ?
If we normalize the
flow, does the AVA
increases ?!

Paradoxixal
low flow AS
?!
Mechanism:
High afterload 
intrinsic myocardial
dysfunction
↓stroke volume

Calcium score Men Women
Very likely ≥ 3000 ≥ 1600
Likely ≥ 2000 ≥ 1200
Unlikely < 1600 <800

• ↑ BNP is a predictor of mortality in low flow –
low gradient AS
• ↑ BNP (> 3 folds ) in asymptomatic patients
with severe AS is class IIa indication for SAVR
• Confirmed by repeated measurements
• No other explanation.
Is there any role to laboratory
investigations to determine AS
severity?

 Assessment of severity of AS (Calcium score)
 Low flow low gradient, EF<50% in the absence of
contractile reserve on stress dobutamine ECHO.
 Low flow low gradient, EF>50% (Integrated approach)
 Diagnostic work-up before TAVI :
◦ Assessment of aortic valve and root.
◦ Related anatomy.

Which of the following is not an indication for
hemodynamic assessment of aortic stenosis via
cardiac catheterization?
 A. Prior to surgical aortic valve replacement
to confirm the severity
 B. When echocardiography is suboptimal
 C. When the parameters measured during
echocardiography are of questionable
accuracy

Various patient factors will influence the type of
therapy recommended, including:
 Clinically stable or not ?
 The presence or absence of symptoms
 Cardiac function and severity of stenosis
 Presence of surgical risk/ risk factors

 A) Follow up
 B)Medical treatment
 C) Balloon aortic valvuloplasty
 D) Transcatheter aortic valve implantation
(TAVI)
 E) Surgical aortic valve replacement

AS mangement
Initial
Medical therapy
Balloon
Valvuloplasty
Definitive
Symptomatic
Low surgical
risk
SAVR
High surgical risk/
risk factor
TAVI
SAVR
Asymptomatic
Severe AS
FU:6 mo/Sx SAVR
EF<50%
Undergoing
cardiac surgery
+ve ET Risk facotrs
Non-severe AS
Requiring
cardiac surgery
SAVR
Not requiring
cardiac surgery
Follow up
Does it improve
QoL/survival ?
ACC

Follow up
• More frequent in case of severe calcification/ elderly
• What to follow ?
– Symptoms ( if doubtful  exercise test)
– ECHO
– Natriuretic peptides (IIa) 0.51 2345

45- A 60-year-old male presents for evaluation of a murmur. He
exercises by walking his dog two miles daily without limitations. He has
a history of hypertension and hyperlipidemia. His medications include
amlodipine 5 mg daily and atorvastatin 20 mg daily. On examination,
his heart rate is 70 bpm, blood pressure is 128/80 mm Hg, and jugular
venous pressure is 4 cm H20. His lungs are clear. His cardiac exam
shows a soft systolic ejection murmur radiating to the carotid arteries.
His extremities have no edema. His echocardiogram shows an ejection
fraction of 60% and aortic stenosis (AS) with a peak velocity of 2.3
m/sec, mean gradient of 13 mm Hg, and a valve area of 1.8 cm2.
In the absence of new symptoms, what is the appropriate interval for a
repeat echocardiogram in this patient?
• A. 2 years.
• B. 6 months.
• C. 3 years.
• D. 6 years.
• E. 1 year.

50- A 50-year-old male presents to your office for follow-up of aortic stenosis
(AS) and an aortic aneurysm. He is active and exercises regularly without
symptoms. He takes no medications. On physical examination his blood
pressure is 110/70 mm Hg with a heart rate of 66 bpm. The carotid contour is
normal. A systolic click and grade 2/6 early-peaking systolic ejection murmur
are heard at the right upper sternal border. The aortic component of the S2 is
preserved. There is no diastolic murmur and no S3 or S4. His peripheral
examination shows no edema. His TTE demonstrates bicuspid aortic valve
(BAV) and the following:
• Left ventricular EF of 60%
• LVEDD of 5.0 cm
• Ascending aorta dimension of 4.6 cm
• Aortic root diameter of 3.8 cm
• Left atrial volume index of 32 ml/m2
• Mean aortic valve gradient of 10 mm Hg
• Aortic valve area of 2.0 cm2
When should the next echocardiogram for surveillance be performed on this
patient?
• A. 2 years.
• B. 1 year.
• C. 3 years.
• D. 5 years.

• What pharmacotherapy has been proven to
reduce mortality in patients with aortic valve
stenosis?
• A. Angiotensin converting enzyme
inhibitors (ACE inhibitors)
• B. Beta-blockers
• C. Diuretics
• D. Spironolactone
• E. None of the above

 No medical treatment that has been shown to
improve survival in patients with aortic
stenosis
 No role of statins(III)/RAAS blockers/
Bisphosphonate.
 Avoid vigorous physical activity in severe AS
 TTT of co-existing HTN

 Prophylaxis for rheumatic fever
 Maintenance of sinus rhythm
 HF :
◦ Cautious use of diuretics and ACEi
◦ Severe decompensated AS ; NYHA IV (Vasodilator
therapy ; Sodium nitroprusside ) IIB ACC
 Post intervention:
◦ Anithrombotics.
◦ Prophylaxis against IE

Which of the following is an indication for aortic
valvuloplasty?
• A. A 78 year old female with symptomatic severe
aortic stenosis that is refusing surgical aortic
valve replacement.
• B. A 83 year old male with symptomatic severe
aortic stenosis needing non-cardiac urgent
surgery
• C. Congenital aortic valve stenosis
• D. Both A and C are indications
• E. Both B and C are indications
• F. All of the above

 A bridge to SAVR or TAVI.
 Indications :
◦ Cardiogenic shock/ severe HF.
◦ Pregnancy
◦ Major non cardiac surgery
◦ Severe comorbidities
◦ Refusal of intervention
 Drawbacks:
◦ Acute severe AR.
◦ Restenosis at 6 months in 30% of pts
◦ 3% is the procedure mortality
◦ 45% is the one-year mortality.

• Which of the following is NOT an indication for aortic valve
replacement?
• A. An asymptomatic patient with severe aortic stenosis when the
left ventricular systolic function reduced to 45% from normal 1 year
prior.
• B. A dyspneic patient with a mean pressure gradient of 42 mmHg
across the aortic valve
• C. A patient with an aortic valve area of 0.9 cm2 who was able to
exercise 12 minutes on a Bruce protocol and complains of no
symptoms
• D. A patient with a mean aortic valve pressure gradient of 30
mmHg, left ventricular ejection fraction of 30% and a dimensionless
index of 0.20.

• Which of the following is an indication for TAVR?
• A. Severe symptomatic aortic stenosis from senile calcific
degeneration in an otherwise healthy 95 year old male
• B. Severe symptomatic aortic stenosis from senile calcific
degeneration in a 90 year old female with oxygen dependent
emphysema not a candidate for surgical aortic valve replacement
• C. Severe asymptomatic aortic stenosis from senile calcific
degeneration in an individual not a candidate for surgical aortic
valve replacement
• D. Severe symptomatic aortic stenosis in a patient with a bicuspid
aortic valve and not a surgical candidate for aortic valve
replacement

The Evolut Low Risk Bicuspid Study
ACC20
TAVR’s safety for severe aortic stenosis in relatively
young, healthy patients who have a bicuspid valve

Would you perform prophylactic
SAVR?

16-A 76-year-old male with a past history of coronary artery bypass
grafting 20 years ago is admitted with progressive dyspnea on
exertion. He has diabetes mellitus, stage 3 chronic kidney disease,
hypertension, dyslipidemia, and had a stroke 5 years ago that left him
with residual left-sided weakness. His echocardiogram shows a mildly
dilated left ventricle, a left ventricular ejection fraction of 25-30% with
regional variations, and severe aortic stenosis (AS) with a mean
gradient of 50 mm Hg and a calculated valve area of 0.8 cm2. Coronary
angiography demonstrates patent grafts and severe native vessel
disease.
• What is the most appropriate next step in the management of this
patient?
• A. Transcatheter aortic valve replacement.
• B. Valved apical-aortic conduit.
• C. Balloon aortic valvuloplasty.
• D. Left ventricular assist device.
• E. Dobutamine infusion.

A 79-year-old woman is reviewed in cardiology clinic as part of the
ongoing assessment for possible intervention for severe aortic
stenosis. The patient had been diagnosed with severe aortic
stenosis 4 months previously, after experiencing progressive
exertional breathlessness and reduced exercise tolerance. At her
initial review at cardiology clinic, the patient had expressed
interest in undergoing intervention for aortic stenosis: either
(SAVR) or (TAVI).
Subsequently, the patient had undergone a variety of
investigations to assess her suitability for the above procedures.
The patient had a good functional status, living independently
with her daughter and still participating in a wide range of
community activities. The patient had a long-standing diagnosis of
hypertension and had suffered a left cortical stroke 3 years
previously. In addition, the patient had COPD . She is on
amlodipine, ramipril, clopidogrel and ipratropium.

TTE reveals AVA of 0.85 cm2; no other valve disease; normal systolic
function.
CA: No evidence of coronary artery disease.
Iliofemoral angiography : Severe calcification and tortuosity of iliac arteries .
PFTs: Moderate obstructive lung disease.
Following the above assessment, SAVR was estimated to carry a 4.1 % risk of
mortality and 3.7 % risk of permanent stroke (intermediate risk).
No contraindications to transapical transcatheter aortic valve insertion were
identified.
What is the recommended choice of intervention for the patient's aortic
stenosis?
A.Surgical aortic valve replacement and transcatheter aortic valve insertion
B.Surgical aortic valve replacement with mechanical valve
C.Transapical transcatheter aortic valve insertion
D.Surgical aortic valve replacement with bioprosthetic valve
E.Transfemoral transcatheter aortic valve insertion

A 76-year-old woman is brought into the Emergency Department following an episode
of loss of consciousness.
On examination, her pulse was 80 bpm, blood pressure 104/89 mmHg, and respiratory
rate 16 breaths/min . She had a slow rising pulse, and on auscultation of the chest
there was an ejection systolic murmur heard loudest at the aortic area, and radiating
to the carotid arteries. ECG shows sinus rhythm and criteria for LVH . CXR shows clear
lung fields.
TTE : Aortic valve area 0.8 cm² (3-4) , Transvalvular gradient 55 mmHg
The diagnosis of aortic stenosis is explained to the patient, and she opts for open
surgical valve replacement.
What other investigation is warranted before proceeding to aortic valve replacement?
A.Exercise tolerance testing
B.Dobutamine stress echocardiogram
C.24 hour holter ECG
D.Transoesophageal echocardiogram
E. Coronary angiography

55- You are asked to see a 59-year-old female with aortic stenosis (AS). For
the past 3 months she has noted progressive shortness of breath with daily
household chores.
Examination is consistent with severe AS . There is no diastolic murmur. Labs
are normal. Her echocardiogram demonstrates concentric left ventricular
hypertrophy with an ejection fraction of 65%. There is a bicuspid aortic valve
with AS; peak velocity is 4.2 m/sec with a mean gradient of 42 mm Hg and a
calculated valve area of 0.7 cm2.
Coronary angiography reveals a 60% angiographic stenosis of the mid left
anterior descending (LAD) artery; fractional flow reserve (FFR) was 0.89.
Her estimated operative mortality for cardiac surgery is calculated at 1.6%.
• Which of the following is the next best step in the management of this
patient?
• A. Surgical aortic valve replacement plus coronary artery bypass
grafting.
• B. Transcatheter aortic valve replacement plus percutaneous coronary
intervention.
• C. Surgical aortic valve replacement.
• D. Transcatheter aortic valve replacement

1- SAVR or TAVI ?
2- >70% or 50-70% ?

 Mr.X is 50 years old, candidate for
cholecystectomy, referred to you for pre-
operative consultation .
 Mr. X has no significant medical history and
has no cardiac symptoms.
 Labs are all within normal
 TTE shows : LV EF: 55% , MPG across AV : 50
mmHg, AVA= 0.8 cm2

• 9-A 48-year-old male presents for evaluation of bicuspid aortic
stenosis because of worsening shortness of breath over the past
few months. He is an avid motorcyclist and despite a recent
accident, would never consider not riding. His echocardiogram 6
months ago showed normal biventricular function, a peak
transaortic velocity of 4.2 m/sec, peak transaortic gradient of 72
mm Hg, mean gradient of 48 mm Hg, and calculated aortic valve
area of 0.8 cm2. His aortic root is a normal size. His past medical
history is significant for hypothyroidism. On exam today his blood
pressure is 128/66 mm Hg, heart rate is 72 bpm, and he has a
normal S1 and a late peaking harsh systolic murmur. His lungs are
clear to auscultation bilaterally and he has no peripheral edema.
Which of the following is the next most appropriate step in the care of
this patient?
• A. Transesophageal echocardiogram.
• B. Repeat transthoracic echocardiogram in 1 year.
• C. Bioprosthetic aortic valve replacement.
• D. Exercise stress testing.
• E. Mechanical aortic valve replacement.

8-You are meeting a 54-year-old male who has recently relocated and
seeks to establish cardiovascular care. He underwent aortic valve
replacement with a low-profile bileaflet tilting disk valve and
simultaneous aortic root replacement at the age of 51 due to bicuspid
aortic valve disease with an ascending aortic aneurysm. His primary
concern for this visit is to seek an alternative to warfarin, because he
was admitted with gastrointestinal bleeding from gastritis 2 months
ago. He has no other medical problems. His current medications are
aspirin 81 mg and warfarin dosed to maintain an international
normalized ratio (INR) of 2.0-3.0. His cardiac exam reveals crisp S1 and
S2 sounds.
Which of the following do you recommend for this patient?
A. Continue warfarin and aspirin.
B. Adjust warfarin for an INR of 1.5-2.5.
C. Stop aspirin.
D. Replace aspirin with clopidogrel.
Replace warfarin with dabigatran

10- A 71-year-old male with a history of a bioprosthetic aortic valve
replacement 16 years ago for endocarditis returns for routine follow-
up. He denies any symptoms of exertional dyspnea, chest pressure, or
dizziness. His examination reveals a grade 3/6 mid-peaking systolic
ejection murmur and a mild diastolic murmur. An S4 is present. His
echocardiogram shows a left ventricular (LV) ejection fraction of 55%,
an LV end-diastolic diameter of 4.9 cm, an LV end-systolic diameter of
2.3 cm, and LV wall thickness of 1.1 cm. Peak aortic velocity is 4.3
m/sec and mean aortic gradient is 44 mm Hg. The aortic valve area is
0.9 cm2 with mild aortic regurgitation and there is no tricuspid
regurgitation jet to estimate pulmonary pressures.
Based on these data, which of the following is the next best step in the
management of this patient?
• A. Dobutamine stress echocardiogram.
• B. Exercise testing.
• C. Transesophageal echocardiogram.
• D. Refer for aortic valve replacement

12-A 55-year-old female presents with a 6-month history of progressive
dyspnea on exertion. She has a history of hypertension and hyperlipidemia.
Her medications include amlodipine 5 mg daily and atorvastatin 20 mg daily.
On examination, her heart rate is 76 bpm and irregular; her blood pressure is
126/70 mm Hg. Her jugular venous pressure is 8 cm H20 with prominent v
waves. Her lungs are clear. Her cardiac exam reveals a brief, high-pitched
sound after S2 followed by a low-pitched rumble, best heard at the apex at
held expiration. Her extremities have no edema. A transthoracic
echocardiogram (TTE) reveals an ejection fraction of 60% with thickened
mitral leaflets, reduced motion during diastole, and doming. The mean mitral
valve area is 1.2 cm2. There is moderate tricuspid regurgitation with an
estimated right ventricular systolic pressure of 55 mm Hg.
Which of the following studies is necessary to determine the correct
treatment approach for this patient?
• A. Cardiopulmonary exercise stress test.
• B. Exercise stress echocardiogram.
• C. Transesophageal echocardiogram.
• D. Cardiac magnetic resonance imaging.
• E. Right heart catheterization.

40- A 51-year-old male is referred for evaluation of a chronic murmur. At 20
years of age, he underwent surgical repair of bicuspid aortic valve (BAV)
stenosis. The patient has been followed intermittently and has no other
significant medical history. He is physically active and asymptomatic, regularly
running 5 miles without limitation. On physical examination his heart rate is
regular at 60 bpm and he has a blood pressure of 135/55 mm Hg. His lungs are
clear to auscultation. Left ventricular (LV) apical impulse is enlarged and laterally
displaced to the anterior axillary line. A grade 2/6 early-peaking systolic murmur
and a decrescendo grade 2/4 diastolic murmur both are present along the left
sternal border. The S2 is soft. There is no S3 or S4. Peripheral examination
demonstrates a pulsatile uvula and a collapsing water hammer radial pulse.
The patient undergoes TTE that demonstrates BAV. LVED is 6.5 cm, LVES is 4.2
cm, and LV EF is 57%. There is severe aortic regurgitation by color Doppler and
aortic root diameter is 4.2 cm.
• Which of the following is the next best step in the management of this
patient?
• A. Symptom-limited exercise stress test.
• B. Serial echocardiography.
• C. Surgical aortic valve replacement.
• D. Transcatheter aortic valve replacement.

Aortic stenosis

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