Aortic insuficiency
Chih Hao Chen Ku
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Hi. I惴 an intern at Hospital San Juan de Dios, in San Jose, Costa
Rica. I惴 making my rounds on the cardiovascular surgery ward. We have
an interesting case in there that I would like to hear your thoughts
about it:
It愀 a 55 years old male, school teacher, that in 1995 started with
dyspnea and a heart murmur was found. An aortic insufficiency diagnosis
was made; in that moment an echocardiogram revealed an eyection fraction
of 35%. He also was found to have chronic obstructive pulmonary disease,
with a 68% pulmonary function. At this time, he presented acute renal
failure, probably secondary to aminoglucosides use. The patient was sent
home with the following treatment: aspirin, warfarin, digoxin,
teofiline, albuterol, cimetidine, and furosemide.
In january 27, 1997, the patient was hospitalized again for a
possible surgery. In this time, his BUN was 51 mg/dl, creatinine 2.9
mg/dl. The other laboratory studies was found to be normal. An
echocardiography showed a dilated left ventricle with global
contractility conserved; mitral valve with mild fibrosis and a dilated
mitral ring; aortic valve not calcificated, with plail; an eyection
fraction of 65% was found.
The most recent laboratory test show a BUN in 117 mg/dl, creatine in
4.5 mg/dl.
The question is: is this a patient for surgery or not?
I would like to hear your thoughts. Thanks.
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<DT> Hi. I´m an intern at Hospital San Juan de Dios, in San
Jose, Costa Rica. I´m making my rounds on the cardiovascular surgery
ward. We have an interesting case in there that I would like to hear your
thoughts about it:</DT>
<DT> It´s a 55 years old male, school teacher,
that in 1995 started with dyspnea and a heart murmur was found. An aortic
insufficiency diagnosis was made; in that moment an echocardiogram revealed
an eyection fraction of 35%. He also was found to have chronic obstructive
pulmonary disease, with a 68% pulmonary function. At this time, he presented
acute renal failure, probably secondary to aminoglucosides use. The patient
was sent home with the following treatment: aspirin, warfarin, digoxin,
teofiline, albuterol, cimetidine, and furosemide.</DT>
<DT> In january 27, 1997, the patient was hospitalized
again for a possible surgery. In this time, his BUN was 51 mg/dl, creatinine
2.9 mg/dl. The other laboratory studies was found to be normal. An echocardiography
showed a dilated left ventricle with global contractility conserved; mitral
valve with mild fibrosis and a dilated mitral ring; aortic valve not calcificated,
with plail; an eyection fraction of 65% was found. </DT>
<DT> The most recent laboratory test show a BUN in 117
mg/dl, creatine in 4.5 mg/dl.</DT>
<DT> </DT>
<DT> The question is: is this a patient for surgery or
not?</DT>
<DT> I would like to hear your thoughts. Thanks. </DT>
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FN:Chih Hao Chen Ku
N:;Chih Hao Chen Ku
EMAIL;INTERNET:cc...@cariari.ucr.ac.cr
NOTE:http://cariari.ucr.ac.cr/~cchen
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Andrew Chung
He is not ready for surgery right now because his renal function is not
stable. My guess is that he may have been over-diuresed (increased LVEF
with pre-renal azotemia). You have to realize that any information from
this newsgroup is going to have to be tempered with the fact that
neither the complete chart nor the patient are available for full
assessment. I would be very worried about pulmonary function as well as
the possibility of related cor pulmonale.
Numbers from a Swan-Ganz catheter would be very helpful.
He would have benefited from an Ace-Inhibitor as part of his Rx at home.
--
Andrew Chung
http://userwww.service.emory.edu/~achung
Paul Lee
Here is my humble thought on this case:
(1) This gentleman has a previous measurement of low ejection fraction
(EF), but now it is normal. However, the LV is dilated (what is he
end-systolic LV dimensions (ESLVD)?), and in addition, he had dyspnea at
some point, presumably secondary to AI (+COPD). It is well known that
ejection fraction deteriorates late in AI, and the goal is to operate
before EF goes down. An ESLVD higher than 55 mm, without surgery, will
result in a mortality of 75% in one year, and 50% in 3 years.
Therefore, if BUN/Cr is not an issue, and assuming his ESLVD is above 55
mm, surgery is indicated. Chronic renal failure by itself has a much
lower mortality than AI with dilated ventricle.
(2) The next question is: in view of renal failure, is surgery possible,
and does it entail high risk? Almost for sure, his kidney function will
deteriorate after surgery as a result of cross-clamping. Renal failure
also does result in higher surgical risk. Calculation of his severity
score (Higgins T. et al. JAMA 267;2344: 1992) shows that he belongs to
medium risk group (COPD=2; Cr>1.9 = 4; Total score=6...medium risk).
Therefore, it depends on how good the medical center and how good the
surgical mortality is. It is expected that he will need permanent
dialysis, and that he may need longer ICU stay.
In summary, in a good center with good surgeon, assuming his ESLVD is
above 55 mm, surgery is the ideal option. But bear in mind that
medicine is an art of weighing risk and benefit, factoring in
personality (of patient and doctor).
Paul Lee
Standard DIsclaimer
Paul Lee
An additional point is that he probably should be "tuned up" before
surgery, given that his BUN is > 100. I agree with Dr Chung that he may
be over-diuresised. I don't think ACE-inhibitor would be wise because
it may worsen renal function. Other vasodilators have been shown to be
useful in AI, such as hydralazine.
Paul Lee
Standard Disclaimer
Robert Coe
On Sun, 02 Mar 1997 15:14:28 -0800, Paul Lee <leex...@tc.umn.edu>
wrote:
: An ESLVD higher than 55 mm, without surgery, will result in a
: mortality of 75% in one year, and 50% in 3 years.
Hmmm.... I'm no physician; in fact I'm not even sure what an ESLVD is.
But I was a math major in college, and that statement doesn't compute.
(Unless, of course, you've found a way to resurrect one third of the
patients who died in the first year. In which case, I'm sure the Nobel
Committee will be contacting you soon!) ;^)
--
___ _ - Bob
/__) _ / / ) _ _
(_/__) (_)_(_) (___(_)_(/_____________________________________ b...@1776.COM
Robert K. Coe ** 14 Churchill St, Sudbury, MA 01776-2120 USA ** 508-443-3265
Paul Lee
You are right. The statement should read "An ESLVD higher than 55 mm,
without surgery, will result in a survival of 75% in one year, and 50%
in 3 years." Sorry for the error.
ESLVD is end-systolic left ventricular dimension. This abbreviation was
defined in my original post. It is a standard measurement on
echocardiographic exam for aortic insufficiency.
Paul Lee
An ex-math wizard