|CLINICAL IMAGE: REPUBLICATION
|Year : 2018 | Volume
| Issue : 4 | Page : 214-215
Critical aortic stenosis
Robert D Cooper1, Julian Macedo1, David P Bahner2
1 Department of Emergency Medicine, The Ohio State University Medical Center, Columbus, OH, USA
2 Department of Emergency Medicine, The Ohio State University Medical Center, Columbus; OPUS 12 Foundation, Columbus Chapter, OH, USA
|Date of Web Publication||18-Dec-2018|
Dr. David P Bahner
Department of Emergency Medicine, The Ohio State University Medical Center, Columbus, OH 43210
Source of Support: None, Conflict of Interest: None
| Abstract|| |
A case of a 52-year-old male with ventricular tachycardia and atrial fibrillation associated with aortic stenosis is outlined. Focused cardiac ultrasound images obtained in the emergency department are presented. A discussion of aortic stenosis and emergency ultrasound in the above clinical context is included.
Republished with permission from: Cooper RD, Macedo J, Bahner DP. Bedside sonography primer: Critical aortic stenosis. OPUS 12 Scientist 2011;5:11-2.
Keywords: Bedside sonography, critical aortic stenosis, diagnostic imaging
|How to cite this article:|
Cooper RD, Macedo J, Bahner DP. Critical aortic stenosis. Int J Crit Illn Inj Sci 2018;8:214-5
| Introduction|| |
The American College of Emergency Physicians and the American Society of Echocardiography have established a definitive role for focused cardiac ultrasound in the emergency department (ED). Within this paradigm, patients who are hemodynamically unstable with a likely cardiac etiology are evaluated for intravascular volume status and global left ventricular systolic dysfunction., We describe a case of a middle-aged man who presented with symptomatic critical aortic stenosis and was promptly diagnosed using bedside sonography in the ED.
| Case Presentation|| |
A 52-year-old male with a history of end-stage renal disease and atrial fibrillation presented to the emergency department with acute hypotension. The patient had chest pain, presyncopal symptoms, and a blood pressure that was too low to be obtained by manual blood pressure cuff. He was initially in atrial fibrillation with rapid ventricular response, featuring intermittent 10–15 s runs of ventricular tachycardia. The remainder of the patient's medical history was unknown. A focused bedside echocardiography was immediately obtained to assess the patient's cardiac status. On ultrasound, the patient was noted to have “severe-to-critical aortic stenosis” and moderate mitral stenosis. The decision was made to immediately bolus the patient with fluid and to perform synchronized cardioversion at 200 joules. Subsequently, the patient returned to normal sinus rhythm with a blood pressure of 121/79. The reader is referred to [Figure 1] and [Figure 2] for key details of the sonographic appearance of critical aortic stenosis in this particular case.
|Figure 1: Parasternal long-axis view of the heart. The right heart is in the near field and the left heart is in the far field. The depth of the aortic valve and the outflow tract is between 5 and 8 cm. Note the enlarged and stenotic AV as well as the stenotic MV. AV: Aortic valve, MV: Mitral valve|
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|Figure 2: Apical view of the heart. The depth of the aortic valve is 10 cm. Note that all three leaflets of the aortic valve can be seen as hyperechoic structures. The aortic outflow tract is located just far field from the valve. The stenotic mitral valve is just to the right of the aortic valve. AV: Aortic valve, MV: Mitral valve|
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The patient described herein underwent a comprehensive transthoracic echocardiogram after admission which redemonstrated the findings made on ultrasound in the emergency department.
Causes of ventricular tachycardia include long QT syndromes, hyperkalemia, cardiac ischemia, heart failure, and aortic stenosis. In patients with unstable ventricular tachycardia, treatment involves synchronized cardioversion and an amiodarone infusion. In a patient on hemodialysis, other potential causes of arrhythmias such as hyperkalemia, fluid overload, or other metabolic disturbances can cloud the clinical picture when choosing emergent treatment in the setting of hemodynamic instability. As this case demonstrated, bedside ultrasound can help identify cardiac abnormalities which can focus a broad-based differential into a specific treatment plan.
Aortic stenosis should be suspected in patients presenting with syncope, angina, and heart failure. Atrial fibrillation and nonsustained ventricular tachycardia are common arrhythmias associated with aortic stenosis. Patients with aortic stenosis often have ventricular tachycardia during syncopal episodes. It is critical to remember that patients with aortic stenosis are preload dependent and require aggressive fluid support to maintain their cardiac output. Atrial fibrillation typically causes more severe symptoms in the setting of aortic stenosis due to the noncompliant left ventricle and the resulting greater need for atrial contraction.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Justifications for republishing this scholarly content include as follows: (a) the phasing out of the original publication – the OPUS 12 Scientist and (b) wider dissemination of the research outcome(s) and the associated scientific knowledge.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American College of Emergency Physicians. Emergency ultrasound guidelines. Ann Emerg Med 2009;53:550-70.
Labovitz AJ, Noble VE, Bierig M, Goldstein SA, Jones R, Kort S, et al.
Focused cardiac ultrasound in the emergent setting: A consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr 2010;23:1225-30.
Sorgato A, Faggiano P, Aurigemma GP, Rusconi C, Gaasch WH. Ventricular arrhythmias in adult aortic stenosis: Prevalence, mechanisms, and clinical relevance. Chest 1998;113:482-91.
Schwartz LS, Goldfischer J, Sprague GJ, Schwartz SP. Syncope and sudden death in aortic stenosis. Am J Cardiol 1969;23:647-58.
[Figure 1], [Figure 2]