CARDIAC STUDIES
Traneseophageal echocardiogram (7/29/2024, UWMC)
History of coarctation of aorta and subaortic/aortic stenosis s/p Ross and
PVR. TEE for evaluation of subaortic/aortic stenosis. Underlying rhythm
sinus.
Flow acceleration in left ventricular outflow tract with cross-sectional LVOT
area of 1.9 cm2 by planimetry due to presence of subaortic membrane. Note
that this may be an overestimate of the area due to difficult of obtaining a
true cross-section. Anterograde flows with max velocity 3.5 m/s, mean
gradient 26mmHg with focal step-up in LVOT suggestive of significant
moderate-severe subaortic stenosis.
S/p Ross procedure with trileaflet neoaortic valve. Anterograde hemodynamics
difficult to assess in setting of subvalvular stenosis.
Mitral valve structurally normal with trace eccentric regurgitation.
Tricuspid valve structurally normal with trace regurgitation.
Bioprosthetic pulmonic valve not well-seen.
Left ventricle grossly normal in size with moderate concentric hypertrophy.
Normal systolic function without regional wall motion abnormalities.
Right ventricle normal in size and systolic function.
Dilated ascending aortat (4.5 cm).
No pericardial effusion.
Compared to TTE 6/12/2024, LVOT/aortic velocities measure lower on today's
study. Clear subvalvular aortic stenosis now identified. Pulmonic valve not
assessed on today's study.
Patch monitor (6/17/2024, UWMC)
- Predominant rhythm: NSR
- Atrial Tachycardia (AT) 192 episodes, Longest 11.5 m @ Avg 153 bpm up to 197 bpm, Fastest 2.4 m @ Avg 166 bpm up to 201 bpm
- PAC 2.3 %
- PVC <0.1 %
CATH 10/27/2023
- Catheter course:
The right heart catheter was advanced across the RV to PA conduit and bioprosthesis and into the left pulmonary capillary wedge position. The left heart catheter was advanced across the left aortic arch, prolapsed across the neoaortic valve, and advanced into the left ventricle.
- Oximetry:
PA 68%, RFA 93%. Qp/Qs assumed to be 1.0. Systemic Fick cardiac output/index 5.68/2.39. PVR 1.94 Wood units. SVR 12.5 Wood units.
- Pressures:
RA 10, RV 66/11, distal MPA 39/17/27, LPA 39/16/25, L PCW, LV 133/21, ascending aorta 106/60/80, descending aorta 109/60/81.
- Angiography:
A. Selective right coronary artery angiography reveals a nondominant right coronary artery arising from the right coronary cusp. The surgically reimplanted ostium is widely patent. The right coronary artery gives rise to 1 very high acute marginal artery. The right coronary artery continues within the atrioventricular groove as an atretic vessel providing no substantial additional branches.
B. Selective left circumflex coronary angiography reveals a large dominant vessel arising off the left coronary cusp from its own ostium. The left circumflex gives rise to multiple posterolateral branches and a posterior descending artery. Angiographically normal.
C. Selective left anterior descending artery angiography reveals a large vessel arising off its own ostium adjacent to the left circumflex coronary artery. There is an 80% relative narrowing of the ostial left anterior descending artery. The remainder of the vessel is free from obstruction and is otherwise angiographically normal.
Assessment and Plan:
Patient has now undergone invasive hemodynamics revealing mildly elevated right and left-sided filling pressures, a modest 27 mmHg gradient across the RV to PA conduit and bioprosthesis, a mild to moderate 27 mmHg gradient across the left ventricular outflow tract, and no gradient between the a sending and descending aorta. Overall these findings are consistent with the patient's recent imaging showing no evidence of severe left or right outflow tract obstruction. Additional findings include a cardiac index that is mildly depressed at 2.4 L/min/m², high normal pulmonary vascular resistance, and normal systemic vascular resistance. Selective coronary angiography revealed a left anterior descending arising off its own ostium with a relative 70 to 80% stenosis. This was further investigated with a pressure wire revealing an IFR nadir of 0.99 consistent with a hemodynamically insignificant lesion. There is no overt evidence of a cardiac cause for the patient's more recent dyspneic symptoms based on this study.
ASSESSMENT
Patient is an 38 year old male with coarctation of the aorta s/p subclavian flap repair, multilevel LVOT obstruction s/p multiple subAS resections and Ross procedure with RV-PA conduit replacement in 2009 seen in Cardiology clinic for follow up.
With improvement in his symptoms following his significant weight loss on tirzepatide, we agree with continued deferment of cardiac surgery.
He is continuing to take testosterone at the current time. He had discussed this with DR at his last visit but elected to continue, particularly in light of the immense improvement in symptoms he is experiencing.
We discussed the need for ongoing surveillance of left ventricular outflow tract gradients. Will see him back in a couple of months with a transthoracic echo to look at left ventricular outflow tract gradients. We encouraged him to increase aerobic activity. He is going to stop creatine supplements.
- Encouraged ongoing weight loss with his appetite
- No changes to medical therapy today other than stopping creatine
- Follow-up next available slot with Dr. or myself with an echocardiogram to look at left ventricular outflow tract gradients
- CTA reviewed, no hemodynamically significant recoarctation
- Blood pressure and the right arm adequately controlled currently
