41 yr-old man with new-onset dyspnea Yoram Agmon MD - - PowerPoint PPT Presentation

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41 yr old man with new onset dyspnea
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41 yr-old man with new-onset dyspnea Yoram Agmon MD - - PowerPoint PPT Presentation

Jun 15, 2023 247 likes •460 views

41 yr-old man with new-onset dyspnea Yoram Agmon MD Echocardiography Laboratory and Heart Valves Clinic Rambam Health Care Campus Haifa Echocardiography WG May 10 2013 41 yo man PMH - Heavy smoking (30 py) Otherwise healthy -

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41 yr-old man with new-onset dyspnea

Yoram Agmon MD Echocardiography Laboratory and Heart Valves Clinic Rambam Health Care Campus Haifa

Echocardiography WG May 10 2013

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41 yo man

  • PMH
  • Heavy smoking (30 py)
  • Otherwise – healthy
  • Recent-onset symptoms (2 weeks duration; acute onset)
  • Dyspnea
  • Palpitations
  • Echocardiography (elsewhere)
  • LVE / LAE; normal LV function
  • Moderate MR (> moderate ??)  hospitalization
  • Mild pulmonary hypertension
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Hospitalization

  • Physical examination
  • No respiratory distress; O2 sat = 97% (room air)
  • BP = 130/65 mmHg; HR = 88 bpm (regular)
  • Heart – “apical systolic murmur – 2/6”
  • Lungs – small bilateral pleural effusions; mild congestion
  • No jugular venous distention / hepatomegaly / periph. edema
  • CXR
  • Small bilateral pleural effusions
  • Pulmonary venous congestion
  • Lab – normal CBC / routine chemistry
  • Repeat echocardiographic exam
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SLIDE 4

TTE + TEE

  • Mild LVE
  • Hyperdynamic LV (LVEF 70-75%)
  • Moderate LAE
  • Normal RV size / function
  • Mild MR
  • PA pressure – not measurable
  • Moderate systemic venous congestion
  • Estimated RAP ~ 15 mmHg
  • Bilateral pleural effusions
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SLIDE 5
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SLIDE 6
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SLIDE 7

Dx – Ruptured Sinus of Valsalva Aneurysm

  • Non-coronary sinus of Valsalva
  • Left-to-right shunt
  • Non-coronary sinus  RA
  • Continuous (systolic & diastolic) shunt
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SLIDE 8

Additional finding?

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SLIDE 9
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SLIDE 10

SVA & AR

  • AR – relatively common complication of SVA* (± rupture)
  • Mechanism – distortion of respective aortic cusp by SVA
  • Secondary degenerative changes
  • Treatment of AR
  • Surgical Rx of SVA
  • Occasional need for additional aortic valve surgery (AVR)
  • AR – indication for early intervention in SVA (?)

*Liu YL, Ann Thorac Surg 2011;91:542-8

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AR Severity?

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SLIDE 12
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PW Doppler – Supra-sternal

QRS

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SLIDE 14

AR Severity?

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SLIDE 15

Intermittent AR

Respiration-dependent

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SLIDE 16

Intermittent AR

Respiration-dependent

Mid-diastolic frames Expiration

  • Flow via SVA
  • No AR

Inspiration

  • Flow via SVA (?)
  • Severe AR
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SLIDE 17

AR (inspiration)

Intermittent AR

Respiration-dependent

Respiratory s in RA pressure / size / intra-cavitary flow  Intermittent (inspiratory) SVA distortion  Intermittent AR

AR (inspiration)

QRS

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SLIDE 18

Why is flow reversal continuous?

QRS

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SLIDE 19

Flow reversal during inspiration

  • SVA
  • AR

Flow reversal during expiration

  • SVA
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SLIDE 20

Follow-up

  • Cardiac surgery
  • Confirmation of echocardiographic findings
  • Aortotomy  direct sutures & patch closure of defect
  • Right atriotomy  direct sutures
  • No aortic valve intervention
  • Intra-operative TEE & post-operative TTE
  • No residual shunt
  • No AR
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SLIDE 21