A 70 year old man is admitted with shortness of breath and respiratory failure to the intensive care unit. A systolic murmur is audible  on examination. A chest X- ray reveals upper lobe diversion of pulmonary veins.  A transthoracic echo reveals the following. (abnormal values marked with an asterix)

OBSERVATIONS:

TRICUSPID VALVE:                         Normal
PULMONIC VALVE:                        Normal
RIGHT VENTRICLE:                         Normal size and function
RIGHT ATRIUM/IVC:                       Normal
MITRAL VALVE:                              Normal

*LEFT  VENTRICULAR EVALUATION 
Normal LV size. Moderate to severe impairment of systolic function.  EF 25%. No regional wall motion abnormalities. Moderate LV hypertrophy.

*LEFT  ATRIUM:  Mildly enlarged.

*AORTIC VALVE:  Thickened and calcified, with reduced opening. No aortic regurgitation.

Aortic valve area

0.68cm2

(2-4)

Left ventricular outflow tract:    

Maximum velocity

0.55 m/s;

(0.8 – 1.2)

Velocity time integral (VTI)

8.58 cm;

Aortic valv 

Maximum velocity

2.93 m/s;

(<2.0)

Velocity time integral (VTI)

43 cm;

Max pressure gradient
Mean pressure gradient

34 mm Hg
18 mm Hg

(<16)
(<10)

Dimensionless severity index (DSI)              0.19

Based on the above information, what is the likely underlying diagnosis responsible for this patient’s symptoms? Comment on the severity of the underlying diagnosis and provide reasons for your answer.

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College Answer

Severe aortic stenosis (2.0) with impaired LV systolic function. Reasons: Valve area less than 0.7 cm2 (1.5) and DSI less than 0.2.

Pressure gradients may be low in the presence of LV dysfunction

Discussion

This question closely resembles the Question 8.3 from the second paper of 2010.