A 72-year-old woman with a 10-year history of hypertension presents with progressive exertional dyspnea and syncope on exertion for 3 months. On examination, blood pressure is 165/95 mmHg, heart rate 78/min regular. Carotid pulse is slow-rising and low-volume (parvus et tardus). A single loud S2 is heard, followed by a late-peaking systolic ejection murmur best heard at the right upper sternal border, radiating to the carotid arteries. There is no diastolic murmur. Chest X-ray shows a normal cardiac silhouette with no pulmonary edema. Echocardiography reveals a bicuspid aortic valve with severe calcification, an aortic valve area of 0.8 cm², and a peak systolic gradient of 72 mmHg. Left ventricular ejection fraction is 55%. What is the most appropriate management?

Explanation

## Clinical Diagnosis: Severe Aortic Stenosis with Symptoms **Key Point:** This patient has **symptomatic severe aortic stenosis (AS)** with a valve area of 0.8 cm² (severe; normal >3 cm²), peak gradient 72 mmHg, and classic symptoms of exertional dyspnea and syncope — the "terrible triad" of severe AS. ### Severity Classification of Aortic Stenosis | Severity | AVA (cm²) | Peak Gradient (mmHg) | Mean Gradient (mmHg) | |----------|-----------|----------------------|----------------------| | Mild | >1.5 | <36 | <25 | | Moderate | 1.0–1.5 | 36–64 | 25–40 | | Severe | <1.0 | >64 | >40 | This patient: AVA = 0.8 cm², peak gradient = 72 mmHg → **Severe AS**. ### Management Algorithm for Aortic Stenosis ```mermaid flowchart TD A[Aortic Stenosis diagnosed]:::outcome --> B{Symptomatic?}:::decision B -->|No symptoms| C{Severe AS?}:::decision B -->|Symptomatic| D[Intervention indicated]:::action C -->|No| E[Medical therapy + surveillance]:::action C -->|Yes| F[Consider intervention]:::action D --> G{Age & Surgical Risk?}:::decision G -->|Age <70, low risk| H[Surgical AVR]:::action G -->|Age >70 or high risk| I{Anatomy suitable for TAVI?}:::decision I -->|Yes| J[TAVI preferred]:::action I -->|No| K[Surgical AVR or medical]:::action ``` **High-Yield:** **Symptomatic severe AS requires intervention** — either surgical AVR or TAVI depending on age, surgical risk, and anatomic suitability. Medical therapy alone is not curative and carries high mortality risk (sudden cardiac death, heart failure). ### Why Surgical AVR (Not TAVI) in This Patient? 1. **Age 72 with preserved EF (55%):** Excellent surgical candidate; expected perioperative mortality <2–3%. 2. **Bicuspid aortic valve with severe calcification:** TAVI outcomes are less favorable in bicuspid valves due to: - Asymmetric calcification and leaflet anatomy. - Higher risk of paravalvular leak (PVL). - Suboptimal frame positioning. - Increased risk of aortic root rupture. 3. **Normal cardiac silhouette and no pulmonary edema:** Indicates no decompensated heart failure; patient is hemodynamically stable and suitable for elective surgical intervention. 4. **Durability:** Mechanical prosthesis (if age-appropriate) or bioprosthesis provides long-term durability; TAVI durability in bicuspid valves is uncertain. **Clinical Pearl:** The **parvus et tardus pulse** (slow-rising, low-volume carotid pulse) is a classic sign of severe AS, reflecting the prolonged left ventricular ejection time and reduced stroke volume. **Warning:** Do NOT use balloon aortic valvuloplasty (BAV) as a definitive treatment. BAV is a **temporizing measure** for: - Bridge to AVR/TAVI in hemodynamically unstable patients. - Diagnostic tool to assess LV contractility in low-gradient AS. - Palliative measure in patients refusing surgery or deemed inoperable. BAV alone has high restenosis rates (>50% at 6 months) and is not recommended as standalone therapy. [cite:Harrison 21e Ch 297]