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Case of the Week
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Case-of-the-Week Information
The Case-of-the-Week is a presentation of 8 or more video loops to present an important topic in echocardiography. Please reveiw the image or video loops and then answer the questions below. After you have answered the questions you can view the explanation and obtain CME credit (if available).

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Preop Preop TEE or TTE
Intraop An Intraop TEE
IntraopPreOp Intraop TEE or TTE before Operation
IntraopPostOp Intraop TEE or TTE after Operation
IntraopEnd Intraop TEE or TTE at End of Anesthesia
Post Op Postop TEE or TTE
Case of the Month Information Table
IntraopEnd is usually a TEE after the Operation and after some event occured to show a change in the TEE
Aortic Stenosis with Mitral Stenosis - What is the true MV Area?
Case#: 49
AMA CME Units: 0.25 Units
Estimated Time: 15 minutes. You need more cme units to do this COTW for CME (not required). Purchase CME Credits

74 y.o. female with a history of SOB, DOE, and CHF.

What is the severity of the AS?
What is the severity of the MS?
Which MVA is correct (PHT or PISA) and why?
What is your recommendation for this patient?


Case Discussion/CME Questions

The following where found on the echo exam:

AV Vmax 375 cm/sec, VTI 70.5, pAVG 56 mmHg, mAVG 31 mmHg
LVOT Vmax 98.3 cm/sec, VTI 19.5 cm
LVOTd 1.7 cm

AVA by VTI 0.64 cm2, AVA by Vmax 0.60 cm2
SV 44 mls
AV Vmax 329 cm/sec, pAVG 43, mAVG 24 mmHg, VTI 54.9 cm
LVOT Vmax 73.2 cm/sec, VTI 13.1 cm
AVA by VTI 0.54 cm2, AVA by Vmax 0.51 cm2
SV 30 mls

AVA by 2D 0.890 cm2
AVA by 3D 0.505 cm2

MVd 3.78cm

MV VTI 55.9 cm
MV Vmax 170 cm/sec, mMVG 4 mmHg

MV PHT 122 msec, MVA by PHT 1.80 cm2, Vmax 126 cm/sec

MVA by VTI 0.53 cm2

MVA by PISA 0.57 cm2, PISA 0.778 cm, Va 38.5 cm/sec, Vmax 170 cm/sec

TVD 3.13 cm, 3.28 cm

This case represents a case that is seen from time to time where there is mixed valvular stenosis and calculating valve areas can have a major impact on the person's outcome. On the first video of the LV basal SAX view, the LV is hypovolemic which should tip you off that the patient has hypovolemia, MS, or is vasodilated. The severe AS, which is confirmed by 2D and Continuity Equation should rule out vasodilation. SV is small (30-40 mls) so the mAVG and pAVG are falsely decreased despite a normal ejection fraction.

The MVA by PISA is 0.57 cm2 but by PHT it is 1.8 cm2. PHT can be influence by LV compliance and atrial compliance factors and aortic regurgitation. AR will equilibrate the LA-LV pressure more quickly and falsely decrease the PHT. Decreased LV compliance due to LVH/AS will do a similar effect. Also, the low flow state wil falsely lower the mMVG. The PISA method is independent of flow, so, it should be more accurate in this case.

An article from Circulation (1988) compared continuity and PHT measurements for MVA and found that MVA was over estimated in AR whereas the continuity equation was more accurate. Other articles have confirmed that the PISA method is more accurate in the setting of AR.  WIthout AR, the PHT should be fairly accurate (R=0.9) but that is with a normal AV.WIth severe AS and LVH, the PISA method should be more accurate in this case. The cross sectional area by 3D would have been helpful in this case to confirm the MVA calculation.

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