An 84-Year-Old Man With Severe AS and Indeterminate Aortic Annular Dimension

An 84-year-old man with a history of coronary artery disease status post remote coronary artery bypass graft surgery, carotid artery stenosis status post carotid endarterectomy, hypertension, dysplipidemia, temporal arteritis, squamous cell carcinoma of the skin, benign prostatic hypertrophy, renal insufficiency, multinodular goiter, and osteoarthritis status post total knee arthroplasty presented with progressive dyspnea on exertion. Physical examination was notable for a regular rhythm with a harsh, III/VI mid-late-peaking systolic murmur at the base with preserved S2, as well as 1+ carotid pulses with a faint left carotid bruit. The Society for Thoracic Surgeons (STS) risk calculator predicted a mortality risk for aortic valve replacement of 5.9%, and the patient also met 2 frailty metrics (i.e., walker dependence with impaired 5 meter walk time and reduced grip strength).

Transthoracic echocardiography was notable for a calcified aortic valve with mean gradient of 34 mmHg, aortic valve area (AVA) of 1.1 cm2 with indexed AVA 0.5 cm2/m2, and ejection fraction of 54% without other significant abnormalities (Figure 1). Cardiac catheterization revealed patent bypass grafts and severely diseased native circulation, with a mean aortic valve gradient of 44 mmHg. Computed tomographic angiography (CTA) was notable for a large aortic annulus measuring 33 x 24 mm with calculated circumference 89 mm and area 5.8 cm2, as well as highly calcified ileofemoral vessels with minimal common femoral artery diameters of 4-5 mm (Figure 2). It is of note that because of renal insufficiency, a low-dose contrast protocol was used, raising concern regarding the accuracy of the annular measurements.

Figure 1 (Video)

Figure 2 (Image)

Figure 2

What is the best next step?

Show Answer