What is the diagnosis for a 64-year-old male with severe aortic valve stenosis, no aortic valve regurgitation, mild pulmonary hypertension, and normal right atrial pressure, as indicated by echocardiogram findings?

From the Guidelines

This 64-year-old male has severe aortic stenosis that requires prompt referral to a cardiothoracic surgeon for evaluation for aortic valve replacement. The echocardiogram findings clearly demonstrate severe aortic stenosis with a peak velocity of 418 cm/s, mean gradient of 42 mmHg, and aortic valve area of 0.9 cm2, which meet the criteria for truly severe AS as defined by the recent guidelines 1. The patient also has mild pulmonary hypertension likely secondary to the aortic stenosis causing increased left ventricular pressures that transmit backward.

Key Findings and Recommendations

• The patient's LVOT Stroke Volume Index of 40.2 ml/m2 is above the threshold for low flow, which is defined as a stroke volume index <35 ml/m² 1.
• The mean gradient of 42 mmHg is above the threshold for low gradient, which is defined as a mean gradient <40 mmHg (or V max <4 m/sec) 1.
• Surgical intervention is necessary because severe aortic stenosis carries a high mortality risk if left untreated, with average survival of only 2-3 years after symptom onset.
• While awaiting surgical evaluation, the patient should be started on a beta-blocker such as metoprolol 25-50 mg twice daily to reduce cardiac workload, and advised to avoid strenuous physical activity 1.
• Symptoms to monitor and report immediately include chest pain, syncope, shortness of breath, and decreased exercise tolerance.

Rationale for Recommendations

• The guidelines suggest that aortic valve replacement is the definitive therapy for severe AS, with operative mortality ranging from 3-5% in patients below 70 years and 5-15% in older adults 1.
• The patient's normal right atrial pressure and absence of pericardial effusion are reassuring findings that suggest the right heart function is preserved despite the mild pulmonary hypertension.
• The recent guidelines emphasize the importance of prompt referral to a cardiothoracic surgeon for evaluation for aortic valve replacement in patients with severe aortic stenosis 1.

From the Research

Patient Profile

• The patient is a 64-year-old male with severe aortic valve stenosis.
• The peak velocity is 418 cm/s, mean gradient is 42 mmHg, aortic valve area is 0.9 cm2, and LVOT Stroke Volume Index is 40.2 ml/m2.
• There is no aortic valve regurgitation.
• The patient has mild pulmonary hypertension with an estimated pulmonary arterial systolic pressure of 45 mmHg.
• The inferior vena cava is normal with >50% collapse upon inspiration, consistent with normal right atrial pressure of 3 mmHg.
• There is no pericardial effusion.

Treatment Options

• The patient's condition can be treated with either transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) 2.
• The choice of procedure depends on several factors, including clinical judgement and patient preferences.
• TAVI may reduce the risk of certain side effects, while SAVR may reduce the risk of others 2.

Age Considerations

• For patients aged ≤60 years, TAVR use is increasing, but is associated with significantly worse 5-year survival compared to SAVR 3.
• For patients aged ≤65 years, consensus guidelines recommend SAVR over TAVR 3.

Risk Considerations

• The patient's risk profile should be considered when choosing between TAVI and SAVR.
• TAVI may be suitable for patients with low surgical risk, but may increase the risk of permanent pacemaker implantation 4.
• SAVR may be suitable for patients with higher surgical risk, but may increase the risk of certain complications such as stroke and myocardial infarction 2.

Other Considerations

• Balloon aortic valvuloplasty (BAV) may be an option for temporary palliation and symptomatic relief in patients with severe aortic stenosis who are not candidates for surgery or TAVI 5.
• For asymptomatic severe aortic stenosis, SAVR may be associated with lower all-cause mortality and heart failure hospitalization rates compared to conservative treatment 6.