Presentation
History of hypertension which caused chronic kidney disease had a kidney transplant. Nine years later had a kidney rejection. Presents with hypotension during hemodialysis
Patient Data
The aortic valve (AV) is tri-leaflet, thickened, heavily calcified and fairly immobile (reduced motion of the cusps). AV peak velocity:4.1m/s, AV max pressure gradient;65 mmHg, AV mean pressure gradient;41 mmHg, AV area;0.5cm2. Moderate to severe aortic regurgitation; aortic insufficiency pressure half time;260ms.Calcified posterior mitral valve leaflet with tenting.
Preserved left ventricular ejection fraction (LVEF);50-55%. Normal left ventricular cavity size with D-shape due to flattening of the interventricular septum during systole consistent with right ventricular volume overload.
Bi-atrial dilatation dilated right ventricle with reduced longitudinal right ventricular systolic function. Moderate mitral regurgitation, mild to moderate tricuspid regurgitation, and moderate pulmonic regurgitation. Spontaneous echo contrast is seen in all chambers.
Conclusion; severe aortic valve stenosis.
Case Discussion
The occurrence of valvular heart disease is increased in patients with chronic kidney disease, especially in patients with end-stage renal disease, compared with the general population. Consequently, the progression of valvular heart disease is accelerated in patients with chronic kidney disease/end-stage renal disease, exacerbating the already elevated cardiovascular risks. The aortic valve is the most frequently affected, leading to aortic valve calcification, which in turn causes stenosis or regurgitation at an accelerated rate.
Aortic stenosis is the most common valvular heart disease among patients with end-stage renal disease compared with the general population, where cardiovascular calcifications increase with age. Aortic stenosis in chronic kidney disease results from progressive calcific degeneration that occurs earlier and more rapidly compared to people without chronic kidney disease. The accumulation of uremic toxins promotes vascular calcifications due to the alteration of calcium-phosphate homeostasis, inflammation and reduced vascular and systemic levels of calcification inhibition. Symptoms of AS among patients with CKD can be more subtle, including; hypotension during dialysis, peri-dialysis atrial arrhythmias and symptoms of extreme fatigue.
The patient was scheduled for aortic valve replacement surgery.