[HSF] Aortic valve

[Edward Bender]

A couple of days ago I was referred a 79 year old male with myelodysplastic
problems, along with easy fatigability, class 3 heart failure symptoms and a
loud murmur at the aortic area.  The cardiologist did an echo in his office
which showed aortic stenosis (indexed valve area of 0.4 cm2)  He did a right
and left heart cath revealing trivial coronary disease, and mildly elevated
PA pressures.  He did not feel the need to cross the valve since this was so
obviously a stenotic aortic vaalve.  He did, however do a TEE confirming AS.
His office echo purported to also show severe PI.  TEE did not show this.
Do you see where I am going with this case?

I operated on him 2 days ago (minimally invasive approach).  The valve was
tri-leaflet, with easy mobility of the leaflets into a wide open position.
Annulus was about 22 - 23 mm, and there was no  LVOTO by direct inspection
or intra-operative TEE.  There was however a very large amount of heaped up
calcium on the left coronary leaf, and lesser amounts on the other two
leaflets with no restriction of motion.

I could not justify replacing this valve, so I pealed all the calcium off
the leaflets.  This was easy, but left a very thin area on the majority of
the left leaflet, so I sutured in a piece of gluteraldehyde treated
pericardium to bolster the thinned leaflet.  Echo on post-op day 1 showed a
peak velocity of about 2 cm/sec. Which translates into about a 16-20 mm
gradient with trace AI.

My question to the valve experts are:
1. His pre-op Hct was 24.  Coupled with the increased mass of the leaflets,
could this account for a false positive diagnosis of AS?  Does a slower
opening time (assuming increased inertia to get the valve open)  cause an
artificially elevated transvalvar gradient?
2. What do you think the durability of such a repair might be?  Is the
experience with patches to the perforated leaflet secondary to endocarditis
applicable to calcific degeneration pathology?
3. I will not get into the behavior and practice standards questions
regarding the complete workup of potential AS.  Most new cardiologists I
know have learned this lesson.

Thanks for anyone¹s input.

Ed Bender, MD