September 2012 Case of the Month courtesy of Svetlana Zakharchenko

A 94 year old women with a PMH of HTN, HLD and progressive dementia was brought to the ER by EMS for reported syncope. Per the patient’s husband, they were leaving their building and as they walked out the entrance, the patient suddenly collapsed to the ground. He denied any tongue biting, urinary incontinence or seizure-like activity. The patient had loss of consciousness for approximately five seconds. She denied chest pain, palpitations, shortness of breath, or headache prior to her collapse. She denied any prior episodes of syncope.

The patient’s bedside ECHO in the ER revealed the following:

The parasternal long axis video above reveals critical aortic stenosis. Notice the significantly calcified aortic valves which barely open during systole. The calcified valves are producing the common artifact referred to as shadowing. Also note, the hypertrophied left ventricular walls which suggest long-standing aortic stenosis.

The patient was admitted to the Telemetry unit for monitoring. She had one episode of atrial fibrillation and 11 seconds of ventricular tachycardia. She was seen by the cardiology consult and started on metoprolol for rate control. Given the aortic stenosis noted on her ECHO and her syncopal episode, the team avoided giving her vasodilators. The patient’s AV area was 1.6cm2 on ECHO. The patient was discharged to rehab with CT surgery follow up.