Introduction
Aortic stenosis is the most frequent valvular pathology in the developed countries
(1). It is most often due to the calcified or degenerated aortic valve as a manifestation
of ageing.
Sub-valvular aortic stenosis is rare in the adult population being more common in
children accounting for 8-20% of left ventricular outflow tract (LVOT) obstructions
(2). Stenosis degree may change depending on the malformation varying from a minor
ridge to a complete fibrous ring or tunnel.
Although proper timing for surgery is unclear, diagnosis might be more difficult in
the adult patient with transthoracic echocardiography as subvalvular portions of the
LVOT might be shaded by calcium and difficult to visualize. We report a case of a
65 years old lady diagnosed with severe aortic stenosis and scheduled for aortic valve
surgery.
Methods
The patient presented to our department with recent history of shortness of breath
and clinical and transthoracic echocardiographic diagnosis os severe aortic stenosis.
The maximum blood velocity across the aortic valve was 4.8 m sec-1 at continuous Doppler
sampling. She was scheduled for aortic valve replacement. After establishing hemodynamic
monitoring, general anaesthesia induction was performed with remifentanil, propofol
and cisatracurium and maintained as TIVA. According to our protocol, a transesophageal
echocardiography (TEE) was positioned and a baseline TEE was performed.
Results
TEE demonstrated a massive concentric hypertrophy of the left ventricle, a membranous
subaortic stenosis and a normal aortic valve (fig. 1A,1B,1C). Surgery was then halted
as the patient's written consent had been obtained for a valve replacement. Then the
patient was further investigated by ECG gated cardiac CT scan, which confirmed the
subvalvular membrane.
The patient was then operated to remove the subvalvular membrane and a partial septal
myectomy was also executed (fig 1D). She completely recovered and was discharged home
on p.o. day 5.
Discussion
Differential diagnosis between aortic valvular stenosis or stenosis due to a subvalvular
obstruction might be tricky, but is crucial for the operation result. TEE 2D and 3D
imaging recognised the anomaly prior to surgery and so allowed to properly address
the cardiac disease leading to post-operative success.
Perioperative TEE should be performed in a systematic manner according to the current
guidelines (3), but beyond the level of re-confirming the expected findings prior
to surgery. TEE allowed for rapid and thorough recognition of previously undiscovered
pathology leading to proper patient's management and case resolution, so confirming
the importance of perioperative TEE in the setting of surgical treatment of heart
valve diseases.
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Copyright
© 2021 Published by Elsevier Inc.
