Clinical Summary: A 92-year-old man presents to the emergency department with 3 weeks of progressive dyspnea on exertion and orthopnea. A dime sized plantar foot ulcer has limited his recent mobility, but at baseline he swims 12 laps at the local pool and performs all instrumental activities of daily living (IADLs) while serving as the primary caregiver of his wife who has a diagnosis of dementia. He was last hospitalized 2 years ago for a small bowel obstruction and has been evaluated in the emergency department twice since then for mechanical falls with minor injury.

The patient was diagnosed with a heart failure exacerbation and found to have a reduction in his ejection fraction from 45% to 25% and severe aortic stenosis (Vmax 3.8 m/s, mean gradient 36 mmHg, aortic valve area 0.5 cm², dimensionless index 0.17). He proceeds with evaluation for the possibility of transcatheter aortic valve replacement (TAVR). Additional clinical history and data from his hospital evaluation are below.

Medical History and Hospital Data:
Medications: Aspirin 81 mg QD, Carvedilol 3.125 mg BID, Lasix 20 mg QD, Lisinopril 20 mg QD, Lovastatin 40 mg QD, Levothyroxine 300 mcg QD, Allopurinol 100 mg BID, Insulin with meals
Cardiovascular (CV) Comorbidities: Coronary artery disease s/p left anterior descending stent in 1996, ischemic cardiomyopathy, hypertension, hyperlipidemia
Non-CV Comorbidities: Chronic kidney disease stage III, diabetes mellitus, anemia of chronic disease, hypothyroidism, benign prostatic hypertrophy, polymyalgia rheumatica, osteoarthritis s/p right hip and knee arthroplasty
Presenting Vitals: T 36.1° C, HR 86 bpm, BP 109/71, RR 20, O2 saturation 95% on room air
Exam: Notable for 4/6 late peaking systolic murmur with radiation to the carotids, bilateral basal rales, elevated jugular venous pulse (JVP), warm lower extremities with 2+ edema, and a 1x2 cm clean based ulcer on the plantar surface of the foot
Laboratory data: Notable for sodium 127 mEq/L, creatinine 1.0 mg/dL, hemoglobin 11 g/dL, normal liver function tests, albumin 3.8 g/dL, troponin 0.05 ng/mL, brain-natriuretic peptide 1541 pg/mL
Electrocardiogram: Sinus rhythm with 3:2 second degree AV block type 1
Baseline Essential Frailty Toolset Score:¹ 3

Before deciding on whether to proceed with TAVR, the multidisciplinary heart team (MDHT) met to discuss this patient's case. The minimal requirements for a MDHT^2,3 currently include the following: interventional cardiologist, cardiac surgeon, echocardiographic and radiographic image specialist, clinical cardiology valve expertise, heart failure specialist, cardiovascular anesthesiologist, nurse practitioners/ physician assistant, valve coordinator/program navigator, institutionally supported data manager, and hospital administrator representative as necessary.

References

1. Afilalo J, Lauck S, Kim DH, et al. Frailty in older adults undergoing aortic valve replacement: The FRAILTY-AVR Study. J Am Coll Cardiol 2017;70:689-700.
2. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021;77:450-500.
3. Nishimura RA, O'Gara PT, Bavaria JE, et al. 2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: a proposal to optimize care for patients with valvular heart disease: a joint report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2019;73:2609-35.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Cardiovascular Care Team, Dyslipidemia, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Implantable Devices, EP Basic Science, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Statins, Acute Heart Failure, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Interventions and Vascular Medicine, Echocardiography/Ultrasound, Hypertension, Sleep Apnea

Keywords: Aged, 80 and over, Transcatheter Aortic Valve Replacement, Activities of Daily Living, Allopurinol, Carvedilol, Creatinine, Furosemide, Lisinopril, Thyroxine, Aortic Valve, Atrioventricular Block, Stroke Volume, Accidental Falls, Anesthesiologists, Arthroplasty, Replacement, Knee, Caregivers, Coronary Artery Disease, Diabetic Foot, Frailty, Hyperlipidemias, Liver Function Tests, Physical Exertion, Polymyalgia Rheumatica, Prostatic Hyperplasia, Systolic Murmurs, Aortic Valve Stenosis, Electrocardiography, Echocardiography, Heart Failure, Hospital Administrators, Renal Insufficiency, Chronic, Emergency Service, Hospital, Natriuretic Peptides, Nurse Practitioners, Lower Extremity, Chronic Disease, Hypothyroidism, Cardiomyopathies, Osteoarthritis, Hypertension, Hemoglobins, Dyspnea, Dementia

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