Emergency department diagnosis of critical aortic stenosis using bedside ultrasonography
© Springer-Verlag 2010
Received: 26 August 2010
Accepted: 26 October 2010
Published: 10 November 2010
An 88-year-old woman with a history of coronary artery disease, hypertension, and a history of a large left upper lobe lung mass presented to the Emergency Department (ED) from a nursing home with rapidly progressive shortness of breath and chest pain over 1 day with a rapid decline in mental status. Bedside color Doppler ultrasound para-sternal long-axis examination of the heart revealed severe aortic stenosis. Bedside pulsed-wave and continuous-wave Doppler ultrasound in the apical 5-chamber view revealed critical aortic stenosis using the simplified continuity equation.
Bedside ED cardiac color Doppler, pulsed Doppler evaluation of the left ventricular outflow tract, and continuous-wave Doppler of the aortic valve were used to assist in the diagnosis of critical aortic stenosis.
An 88-year-old woman with a history of coronary artery disease, hypertension, and a history of a large left upper lobe lung mass presented to the Emergency Department (ED) from the nursing home with rapidly progressive and worsening shortness of breath and stuttering chest pain over 1 day with a rapid decline in mental status. Her ED vital signs were temperature 94°F, blood pressure 110/43 mmHg, respiratory rate 38 bpm, and room air oxygen saturation 81% which increased to 99% on 100% oxygen by non-rebreather. Electrocardiogram revealed normal sinus rhythm with a heart rate of 89 bpm and no ischemic changes. On physical examination, she was noted to be a very thin woman in moderate respiratory distress with a right sternal border systolic crescendo-decrescendo murmur and bilateral rhonchi breath sounds. She had no leg edema or tenderness to palpation. Portable chest X-ray showed bilateral pleural effusions and an unchanged left upper lobe lung mass. Initial laboratory studies revealed a BNP of 2,511 pg/mL.
Using the simplified continuity equation, our symptomatic patient’s ED calculated AVA area measurement was 0.28 cm2 and the formal Cardiology calculated AVA measurement was 0.7 cm2, both considered to be critical aortic stenosis in our patient with chest pain and shortness of breath . Our underestimation of the AVA compared to the Cardiology AVA measurement was due to our underestimation of the LVOT diameter, 1.43 versus 2.0 cm Cardiology LVOT measurement. The LVOT diameter measurement is the most common measurement error when calculating the AVA in patients with aortic stenosis as this inner edge to inner edge measurement can be difficult in patients with severe aortic valve calcification, as was the case in our patient . In addition, because the LVOT diameter measurement is squared [π(D/2)2], any LVOT measurement errors are amplified further. Symptomatic patients with critical aortic stenosis are best surgically managed with aortic valve replacement [1–4]. Rapidly identifying a patient with critical aortic stenosis in the ED or intensive care unit can expedite the important cardiothoracic surgical consultation and ultimate surgical treatment that the majority of these patients will require.
Bedside cardiac color Doppler ultrasonography and pulsed Doppler evaluation of the LVOT and continuous-wave Doppler of the aortic valve can assist the emergency physician and the critical care physician in the diagnosis of critical aortic stenosis.
Conflict of interest
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