FM OCTOBER 2018 ISSUE - digital edition

case reports
HOW SHE REGAINED
HER LOST TASTE
A new lease of life to a 70-year-old lady crippled by multiple progressive
heart disorders —thanks to TAVR
DR ANOOP AGRAWAL
Mrs. Sharma (name changed) couldn’t taste her food
anymore. “Just like my hair, my tastebuds are also
aging,” she thought. Mrs. Sharma, at 70 years of age,
had been a well-kept lady until the previous year. She had
enjoyed a healthy, active lifestyle in her youth and adulthood.
With an academic bend of mind, she used to teach until her
early 60s. At around 61 years of age, she was diagnosed with
a bicuspid aortic valve (BAV) that had led to severe aortic
stenosis (AS), and was advised
to undergo surgical aortic
valve replacement (SAVR).
Overwhelmed by the flow
of information, Mrs. Sharma
ended up refusing surgery
at the time. Over the next
few years, she continued to
function independently and
forgot about the deformed
valve sitting in her heart.
Last year, she started
noticing exertional shortness
of breath upon walking a few
hundred meters. Over the
ON THE TOP OF SEVERE
AS, SHE HAD DEVELOPED
SEVERE AORTIC
REGURGITATION, SEVERE
MITRAL REGURGITATION
AND SEVERE LEFT
VENTRICULAR SYSTOLIC
DYSFUNCTION.
next few months, she slowed down her life to compensate
for her exertional symptoms. Slowly, she started developing
dyspnea on walking within her house. She lost interest in
her food. Her sleep was interrupted with frequent episodes
of breathing difficulty. By the time she touched 70, she had
lost almost 9 kg over a period of six months due to early
satiety and ageusia. She was restricted to her room due to
her inability to walk longer distances. Lately, she also started
fainting at home, only to regain her senses after a minute
or two. It was so frequent that it almost became routine for
her and her family. She did seek medical attention for her
progressive illness and came up with unanimous feedback:
“She needed SAVR, but the risk was too high.” Not ready to
undergo a surgery risking her life, she decided to continue
with medicines alone, which obviously
weren’t working.
Sometime during this hustle, she was
referred to me for further evaluation. What
I saw was a thin, frail lady who had to take
periodic pauses in between her sentences to
catch her breath. Even before taking a look
at her medical records, I knew that patients
with that degree of cardiac cachexia rarely
do well with heart surgery. Her medical
records made me concerned. On the top of
severe AS, she had developed severe aortic
regurgitation, severe mitral regurgitation and
severe left ventricular systolic dysfunction.
Essentially, the blood in her heart was flowing
the wrong way. I voiced my concerns to Mrs.
Sharma and her family regarding the gravity
of the situation and that there wasn’t an
easy way out, with or without surgery. I asked
her about her goals in life. “I want to get
back to shopping,” she replied without any
hesitation. We discussed at length about her
options, what we can do without imposing
a significant procedural risk on her. We
discussed about transcatheter aortic valve
replacement (TAVR).
TAVR is a procedure where a
bioprosthetic valve is crimped and loaded
on to a catheter, inserted through groin in
a minimally invasive fashion, and implanted
in place of the diseased aortic valve. TAVR
is approved for patients with severe AS
who are considered higher risk for SAVR.
We discussed Mrs. Sharma’s case with
cardiothoracic surgeons for her eligibility
for surgery. After the surgeons deemed
her very high risk for surgery, we opted for
TAVR, knowing that TAVR will only address
problems related to the aortic valve. This was
nonetheless her best chance.
50 / FUTURE MEDICINE / OCTOBER 2018