HISTORY, CURRENT ILLNESS AND PHYSICAL EXAMINATION

History
62-year-old woman.
No known drug allergies.
Toxic habits: smoker of 1 pack of cigarettes per day (pack-year rate: 40). No alcohol or other intoxicants.
Cardiovascular risk factors: hypertension, dyslipidaemia, type II diabetes mellitus with last HbA1c 7.5% under control by her primary care physician, without diabetic retinopathy. Morbid obesity with muscle mass index (BMI) 49.22 kg/m2 (weight 127 kg, height 161cm).
Chronic coronary syndrome diagnosed in 2012 due to exertional angina with inconclusive stress echocardiogram and initiation of anti-ischaemic, antiplatelet and lipid-lowering therapy. Subsequent coronary angiography in August 2012 with significant stenosis in the mid-distal anterior descending artery with implantation of a drug-eluting stent.
Rest of vessels with mild atheromatosis without significant stenosis.
Diagnosed since 2015 with asymptomatic moderate-severe aortic stenosis. Control echocardiograms showed a non-dilated, moderately hypertrophic left ventricle with good global and segmental systolic function. Sclerocalcified aortic valve with moderate-severe stenosis and valve area estimated by continuity equation of 1 cm. Mild-moderate aortic insufficiency. Sclerosed mitral valve with mild insufficiency. Transmitral flow E<A, suggestive of prolonged LV relaxation. Moderately dilated left atrium. Right ventricle normal in size and function. Mild tricuspid insufficiency with moderate pulmonary hypertension. Moderately dilated right atrium. No pericardial effusion. No aortic root dilatation.
No known bronchopathy.
Repeated urinary tract infections. Hepatic steatosis.
Surgical interventions: umbilical hernia.

Usual treatment: acetylsalicylic acid 100 mg 1 tablet at lunch; olmesartan/amlodipine 20/5 mg 1 tablet at breakfast; bisoprolol 5 mg 1 tablet at breakfast; metformin 850 mg 1 tablet at breakfast and dinner; atorvastatin 20 mg 1 tablet at dinner; esomeprazole 20 mg 1 tablet at breakfast; nitroglycerin spray on demand.
Baseline functional status: housewife. Absolute sedentary lifestyle.

Current illness
Patient under follow-up in cardiology consultations for several years due to chronic coronary syndrome with implantation of a drug-eluting stent in the mid-distal anterior descending artery and asymptomatic moderate-severe aortic stenosis. In the March 2019 consultation, the patient began with previously absent NYHA II-III exertional dyspnoea and occasional nocturnal angina at rest, without syncope, palpitations or other additional cardiological symptoms.

Physical examination
Blood pressure at consultation 130/80 mmHg, heart rate 75 beats per minute. Oxygen saturation 97%.
Conscious and oriented. Well perfused and hydrated. Eupneic at rest. Severe obesity. Pulmonary auscultation: overall decreased vesicular murmur.
Cardiac auscultation: aortic murmur, systolic, radiating towards the carotid arteries.
Abdomen difficult to assess due to obesity, soft, depressible, not painful on palpation. No visceromegaly or masses. Preserved hydro-aerial sounds.
Chronic cutaneous trophic disorders in the lower extremities, with no apparent oedema.

COMPLEMENTARY TESTS
Electrocardiogram: sinus rhythm at 70 beats per minute. Normal PR. Narrow QRS with +30o axis. Left ventricular hypertrophy by Cornell criteria (sum of R wave in aVL and S wave in V3 21mm) with asymmetrical negative T waves in lateral face suggestive of left ventricular systolic overload. Normal QTc.
Transthoracic echocardiogram: poor acoustic window. Non-dilated left ventricle (DVItd 44mm), with moderate concentric hypertrophy (SIVtd 14mm, PPtd 14mm). Global systolic function preserved (LVEF simpson biplane 72%), without regional contractility asynergies. Mild sclerocalcified mitral valve, with no abnormalities in function. Aortic valve trivalve, severe sclerocalcification and restricted opening. Maximum gradient 2 of 121 mmHg and mean of 72 mmHg. Calculated aortic valve area of 0.5-0.6 cm
Mild-moderate aortic insufficiency. Slightly dilated left atrium. Right ventricle poorly visualised, apparently of normal dimensions and systolic function. Tricuspid valve poorly visualised, without significant tricuspid insufficiency. Pulmonary artery acceleration time of 70 msec, suggestive of pulmonary hypertension. Right atrium not dilated. Aortic root of normal size. No pericardial effusion. Blood tests:
Biochemistry: glucose 163 mg/dl, urea 35 mg/dl, creatinine 0.64 mg/dl, glomerular filtration rate calculated by CKD-EPI > 90 ml/min/1.73 m , albumin 4.3 g/dl, Na 142 mEq/l, K 4.9 mEq/l, GPT 28 U/l, GGT 39 U/l. TG 137 mg/dl, total cholesterol 167 mg/dl, HDL 33 mg/dl, LDL 107 mg/dl, non-HDL cholesterol 134 mg/dl.
CBC: haemoglobin 16 g/dl, 244,000 platelets/ul and 10,210 leucocytes/ul. HbA1c 7.5%.
Urine: albuminuria 29.8 mg/dl, creatinine 107 mg/dl, albumin/creatinine ratio 278 mg/g.
Pre-TAVI CT scan: study from pulmonary apex to symphysis pubis with intravenous contrast and selective acquisition of aortic root with cardiac synchronisation. Thoracic aorta of normal calibre and morphology with slight atheromatous changes. Abdominal and iliac aorta of normal calibre and morphology with little atheromatous changes. Maximum and minimum diameters of the valve plane in end-systolic phase: 25 x 21mm. Valvular plane area in end-systolic phase 473 mm. Distance from the valve plane to the origin of the left and right coronary arteries, 12 and 14 mm, respectively. Maximum diameter of ascending thoracic aorta 34 mm, aortic arch and descending thoracic aorta 32 mm. The origin of the supra-aortic trunks is normally visualised. Thoracic aorta and abdominal aorta of normal calibre without tortuosity. Calcified plaques in infrarenal abdominal aorta and common iliac with irregularities without significant stenosis. External iliac and femoral aorta without significant atheromatous changes. Minimum diameter of distal abdominal aorta 14 mm, right common iliac 7 mm, left 7 mm, right external iliac 7 mm, left 7 mm, right common femoral 7 mm, left 7 mm.
Pre-TAVI coronary angiography: common trunk shows mild distal calibre loss not significant. The anterior descending artery shows dense parietal calcification, but no significant stenosis. The circumflex artery is a very poorly developed vessel with no obvious lesions. The dominant and highly developed right coronary artery shows moderate diffuse calcified atheromatosis, with no significant focal stenosis. Conclusion: diffuse calcified coronary atheromatosis without significant focal stenosis.
Intraprocedural transesophageal echocardiogram: ring measured in 2D 22.5 2 mm and in 3D 4.33 cm.
Post-TAVI echocardiogram: non-dilated left ventricle with moderate concentric left ventricular hypertrophy. Global and segmental systolic function preserved. TAVI in aortic position with maximum and mean gradients of 23 mmHg and 11 mmHg, respectively. No aortic insufficiency. Sclerocalcified mitral valve without functional alterations. Transmitral flow suggests prolonged relaxation. Slightly dilated left atrium. Right ventricle normal in size and function. No tricuspid insufficiency, pulmonary artery acceleration time of 80 msec. Inferior vena cava not dilated and inspiratory collapse > 50%. No pericardial effusion. Aortic root of normal size.

CLINICAL EVOLUTION
This clinical case presents a patient with chronic coronary syndrome since 2012 and double aortic lesion with predominant moderate-severe stenosis since 2015, asymptomatic after starting antianginal treatment and implantation of a drug-eluting stent for any cardiovascular symptoms until March 2019. In that year, the patient developed dyspnoea on exertion and the echocardiogram was updated to show a double aortic lesion with predominantly severe stenosis and a critical valve area.
Given that the patient had severe symptomatic aortic valve disease, it was decided to act on it. The risks of surgery were calculated, with a EuroScore II of 1.97% and EuroScore I of 5.30%, and the case was discussed by the heart team.
Despite having a SCORE of low surgical risk according to the scales used, given that the patient was morbidly obese with marked limitation of ambulation, and that these scales do not include factors such as significant obesity with the high surgical risk that this entails, aortic valve replacement surgery was rejected and TAVI was chosen.
A pre-TAVI CT scan was performed which demonstrated the possibility of performing the technique. On the other hand, the patient was referred for endocrinology consultations to manage her diabetes and to try to reduce her weight prior to valve replacement. She was initially seen in June 2019 and several measures were initiated: 1800 kcal diet, increase of metformin dose to 850 mg 1 tablet breakfast, lunch and dinner and initiation of semaglutide to better control her diabetes and attempt weight reduction, initially at a dose of 0.25 mg weekly for the first month and then 0.5 mg weekly from the following month. She was not started on iSGLT-2 due to repeated urinary tract infections.
She progressively lost weight and was seen in pre-anaesthesia consultation in June 2019, with surgical risk ASA-III and included in the surgical list. In October 2019, the operation was performed under general anaesthesia with orotracheal intubation and transesophageal echocardiography. Prior to the procedure, the right jugular vein was cannulated with transient intravenous pacemaker implantation. The left femoral artery was punctured by Doppler ultrasound. The right femoral artery was guided with contralateral angiography, through which a 26th Edwards SAPIEN prosthesis was advanced. During prosthesis implantation the patient developed complete left bundle branch block without atrioventricular block. There was minimal aortic regurgitation by TEE and none by aortography. The right femoral access was closed with Prostar, and the absence of complications was verified by contralateral angiography, and the left femoral access was closed with AngioSeal. The patient was extubated in the ward and transferred in good clinical and haemodynamic condition to the coronary unit. Total procedure time 60 minutes.
During her stay in the coronary unit, the patient remained haemodynamically stable, tending to arterial hypertension, requiring intravenous nitroglycerin during the first hours, which could be suspended later after reintroduction of the usual oral antihypertensive treatment. In sinus rhythm with good heart rate on telemetry, with disappearance of left bundle branch block over the hours and no atrioventricular block of any kind. Respiratory stability, initially with Sa02 < 90% in the context also of the extrapulmonary restrictive disorder due to obesity associated with some pulmonary congestion, which after occasional administration of IV furosemide improved to Sa02 > 94% on room air. Normal renal function with preserved diuresis. Afebrile with low infection parameters. E. coli was isolated in urine > 100,000 CFU/ml covered with antibiotic prophylaxis administered pre-TAVI (curoxime). No complications were observed at the femoral access points, with no haematomas or murmurs, bilateral pedal pulses present and stable haemoglobin in the control tests. Treatment was started with double antiplatelet therapy (acetylsalicylic acid and clopidogrel) and she was transferred to the hospital ward after a 24-hour stay in the coronary unit. She remained on the hospital ward for 4 more days with progressive ambulation and no local or systemic complications, and was discharged home.
The patient is currently being followed in the valvulopathy clinic with complete disappearance of dyspnoea and angina. She is following the diet proposed by endocrinology and oral antidiabetic treatment consisting of semaglutide and metformin, with a last recorded weight of 106 kg, with a weight loss of 21.5 kg and improvement in glycosylated haemoglobin to 5.5%.

DIAGNOSIS
Implantation of TAVI Edwards SAPIEN 3 no 26 for symptomatic severe aortic stenosis. Chronic coronary syndrome with implantation of a drug-eluting stent in 2012.
Preserved LVEF.
Cardiovascular risk factors: hypertension, type II diabetes mellitus, dyslipidaemia, obesity.
