Case 2: Systolic Murmur in a Middle-Aged Man Avery K.

Ellis, MD, PhD August 30, 2011

Required Reading: Lilly LS, Pathophysiology of Heart Disease, 5th edition, Lippincott Williams & Wilkins, Philadelphia, 2011, pp 28-41, 49-51, 56-61, 190-215.

Learning Objectives: After completing this case, you should be able to: Discuss the cardiac lesions that have associated systolic murmurs. Outline the pathophysiology of valvular aortic stenosis. Draw the pressure waveforms found in aortic stenosis and understand the relationship between the pressure tracings, gradients, heart sounds and murmurs. Discuss the clinical symptoms and treatment options in patients with aortic stenosis. Calculate the aortic valve area from cardiac catheterization data. Discuss the pathophysiology of angina, syncope and congestive heart failure in patients with aortic stenosis.

Case History and Questions for Group Study: A 52 year-old man is admitted to the Buffalo VA Medical Center for evaluation of syncope. The patient lives on a farm near Jamestown, NY, and he says that he has recently passed out on three separate occasions while working in the fields. There was no associated seizure activity and no bowel or bladder incontinence. He has also noted some mild dyspnea on exertion which had become slightly worse over the past year. His pediatrician told him that he had a heart murmur as a child, but he has been in generally good health his entire life. He was on various varsity athletic teams while in high school, and he worked on his farm for the past 34 years. He had the usual childhood illnesses and denies a history of rheumatic fever. Except for an appendectomy, he has never been hospitalized. He is on no medications. On physical examination at the time of admission to the hospital, he appears healthy. His blood pressure is 130/80 and his pulse is 84/min. His carotid upstrokes are slightly delayed. His jugular venous pulsations (JVP) are normal and his lungs are clear. On cardiac examination, his PMI is in the 5th intercostal space at the mid-clavicular line. His rhythm is regular. S1 is normal, but S2 is single; a fourth heart sound is present. There is a grade III/VI harsh, late-peaking systolic ejection murmur heard over most of the precordium but best heard in the 2nd right intercostal space immediately adjacent to the sternum; it radiates to the supraclavicular area and to the carotid arteries. Examination

Avery K. Ellis 2011

of his abdomen is benign. His extremities have symmetric pulses and no cyanosis or edema. His neurologic examination is normal.

A.

Draw pressure tracings for two cardiac cycles for this patient; include the left ventricular, aortic and left atrial waveforms. (See page 5 of this case study for some unmarked LV pressure tracings; you can draw the other waveforms directly on this template.) Indicate where the aortic valve opens and closes and where the mitral valve opens and closes. Indicate S1, S2, and S4. Why is S2 single in this patient? Show where the systolic murmur starts and ends in relation to the pressures and heart sounds. Why does it radiate to the supraclavicular area and to the carotids? What does the S4 signify, and why is it present in this patient? Cardiac conditions associated with systolic murmurs include aortic stenosis, mitral regurgitation, pulmonic stenosis and ventricular septal defect. For each of these conditions, draw the appropriate pressure tracings (as you did in A above), indicate S1 and S2, and show where the murmur starts and ends. What are the similarities between aortic stenosis and pulmonic stenosis? (Pages 6-7 at the end of this case have some unmarked LV pressure tracings.) What are the similarities and differences in the heart sounds: (1) between aortic stenosis and pulmonic stenosis, (2) between aortic stenosis and mitral regurgitation, and (3) between aortic stenosis and a ventricular septal defect?

B.

A chest x-ray and an echocardiogram are obtained and are available for your review. A Doppler tracing from the patient is shown below.

1 M/sec

C.

Review the chest x-ray and discuss the findings. Look at the echocardiogram and compare it to the echo from a normal person. Specifically, look at the aortic, mitral and tricuspid valves. Also, note left ventricular size and function of the patient. Based on the Doppler tracing shown above, what is the pressure gradient across the aortic valve?

Avery K. Ellis 2011

D.

What are possible etiologies of aortic stenosis in general? How are the natural histories different in each case? What is the most likely etiology of this patients aortic stenosis?

The patient undergoes a cardiac catheterization, and the left ventricular and aortic pressure tracings are shown. Oxygen saturations are tabulated below, the patients hemoglobin is 14 g/dl, and measured oxygen consumption is 260 ml/min. O2 saturations (%) Right atrium Pulmonary artery Left atrium Left ventricle Aorta 75% 75% 97% 97% 97%

LV

200 mmHg

Ao

100 mmHg

0 mmHg

E.

Study the pressure tracings above. Indicate peak LV pressure and LV enddiastolic pressure. What are the systolic, diastolic and mean aortic pressures? Notice that the upstroke of the aortic pressure is slightly delayed after the LV pressure upstroke. Why does this occur? What is the peak gradient across the aortic valve? What is the mean gradient? The peak-to-peak gradient? Calculate the patients aortic valve area.

Avery K. Ellis 2011

F.

Chest pain, heart failure and syncope are symptoms which may develop in patients with aortic stenosis. What is the pathophysiologic basis for each? What is the prognostic significance of each of these symptoms? What treatment would you recommend for this patient and why?

Question to be turned in: Will the treatment that you recommend to this patient improve his survival (i.e., cause him to live longer) or just improve his symptoms (i.e., make him feel better)? (Improve survival / improve symptoms)

Avery K. Ellis 2011

LV pressure tracings to be used for Case 2, Question A.

A spare, if needed.

Avery K. Ellis 2011

LV pressure tracings to be used for Case 2, Question B.

Avery K. Ellis 2011

Avery K. Ellis 2011