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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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Loop Text Key  
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
The Chicken or the Egg
Case#: 30
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
84 yo female with a history of a SEMI, (normal ECG and an elevated troponin 0.22->2.70) that was treated with ASA and Lovenox in the ER, DVT 20 yrs ago, hypertension, NIDDM, hypothyriodism, and a TIA several years ago. Her current medications include Plavix, Atacand, Glipizide, Levothyroxin, Metformin, Imdur, and Lopressor. She lives alone. Her initial TTE showed an LVEF 50%, Stage 1 diastolic dysfunction, LVH, LAE, RAE, thickened MV leaflets, MAC, mild MR, mild MS, mild AR and severe AS. The mAVG was 30 mmHg with an AVA of 0.89cm2. The AV Vmax is 3.66 m/sec. The MV Vmax was 2.34 m/sec with a mMVG of 8 mmHg and a MVA of 2.72 cm2. The PAP is 38 mmHg. There was inferior and anterior HK present. A cardiac cath showed a LAD 95%, OM 80%, Cx 70%, RCA 80%

Please give your assessment of the intraoperative echo exam.
Why is there a discrepency between the preop AVA and the mean AVG?
How does mitral stenosis affect the aortic valve calculations?
How does aortic stenosis affect the mitral valve calculations?


Case Discussion/CME Questions
The intraoperative echo exam shows severe aortic stenosis from exstensive calcification. The mitral valve has mitral annular calcification and moderate mitral stenosis. The LVEF is normal. The AVG and Vmax indicated moderate aortic stenosis. The calculated AVA is 0.29 cm2 and the measured AVA by 2D is 0.488 cm2. The mitral valve area by 2D is 1.14 cm2. The MVA DT is 377 msec or 595 msec (depending on which slope you are measuring) for a calculated MVA of 2.01 cm2 and 1.27 cm2 respectively. The mean MVG was 3 mmHg.

The preoperative TTE shows a mAVG of 30 mmHg which is moderate aortic stenosis. Also, the AVA calculates to 0.89 cm2 which is severe aortic stenosis. AVG is flow related and since the patient has restricted flow from mitral stenosis the gradient would tend to be lower from a decreased cardiac output. The

Mitral stenosis can be diagnosed by 2D planimetry, Doppler derrived mean MVG and PHT, and mitral valve area from calculations involving PISA and the continuity equation. 2D has the advantage of no flow or confounding factor assumptions but the disadvantage of having a good orifice image to measure and the plane to the narrowest mitral valve opening must be caught in a non-foreshortened view. 3D echocardiography will improve the accuracy of the interrogation plane. MVA by PHT can be calculated using CWD. However, sometimes (as in this case) the deceleration limb of the E wave is bimodal where it is usually rapidly decelerating in early diastole and then a slower deceleration occurs in mid diastole. The recommendation is to use the mid-diastolic wave in the calculations of PHT.  The deceleration phase of the E wave depends upon the MVA, diastolic function of the left ventricle, left atrial compliance, and left ventricular compliance. Aortic regurgitation decreases the PHT measurement whereas impaired LV diastolic function can cause a variable effect. Early LV diastolic dysfunction can prolong PHT but decreased LV compliance can decrease the PHT. Therefore, in severe aortic stenosis the PHT should not be used because it is unreliable.

Aortic stenosis calculations such as aortic valve gradient are depending upon the cardiac output which is impaired in mitral stenosis. Significant mitral stenosis can lower the cardiac output and, therefore, falsely lower the aortic valve gradient.

In this case, the mean MVG was 8 mmHg preop, 3 mmHg intraop, and 7 mmHg postop. The MVA was 2.47 cm2 preop, 1.14 cm2 intraop, and 2.47 cm2 postop. It appears the AVR had little effect on the MVA or MVG calcluations/measurements. Also, the intraop calculations indicated moderate mitral stenosis by MVA and no MS by MVG whereas the preop and postop TTE indicated the absence of MS by MVA, but moderate MS by gradients.

Since gradients are flow related, they were unreliable preoperatively and intraoperatively. Also, since PHT is unreliable in the presence of severe AS, the preop and intraop MVA by PHT (or DT) is also unreliable. It seems the most accurate measurement of the MVA was the 2D measurement intraoperatively. The TTE postoperatively should have had a reliable PHT and MVA calculation.

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