George

Slide 1: George goes to his GP. On auscultation, the GP can hear a heart murmur. Image of George with GP

What does the GP do?
A. An ECG and blood tests?
B. Refer him to a cardiologist?
Feedback: Both. The GP suspects George may have had a heart attack or has heart failure (BNP test).

Slide 2: George goes to see the cardiologist. His ECG is abnormal, shows Left Ventricular Hypertrophy (LVH), he can also hear a loud systolic murmur. Image of normal heart and LVT heart.

What does the cardiologist do?
A. Send George for a treadmill test to see how breathless he gets or if he has angina?
B. Sends George for an echocardiogram.

Feedback: Echo. The echo shows that George has severe aortic stenosis and his left ventricle is rather dilated, that means his aortic valve is calcified and not opening properly leading to raised pressures inside his left ventricle. As it tries harder to squeeze blood through the narrowed valve, this impacts on the walls of the myocardium by causing them to get thicker –hypertrophy – and causing stiffness of contraction which leads to dilation and symptoms of heart failure. See HF module/ hypertension module.

Slide 3: George takes the results back to the cardiologist. Image of ECHO

What does the cardiologist do?
A. Starts him on appropriate medication ( which is?)
B. Refers him to surgical team for valve replacement?
Feedback: Both. The cardiac surgeon wants George to have more tests.

Slide 4: George has a pulmonary function test and a coronary angiogram. Image of George doing a spirometry test and angiogram.

Why?
A. Because George has diabetes?
B. George may have COPD?
C. George’s brother has had a heart bypass.
Feedback: All of those. George has high risk of coronary artery disease. The surgeon has to be sure his coronary arteries are normal and that his lung function is good before surgery. Coronary artery disease, angina can have similar symptoms to AVD. See CHD/ ACS module for more information. With George’s history it is wise to look at the arteries with an angiogram before valve replacement and decide whether George needs a CABG (coronary artery bypass graft) at the same time.

Slide 5: The cardiac surgeon also discusses the type of valve that George would be recommended to have or prefer to have implanted. The options are:

• A tissue valve: biological ( homograft), porcine/ bovine BAVP
• A mechanical valve MAVP

George has a lot to think about. His angiogram and PFTs are normal. He does some investigation on the internet – what about this new operation that requires no open heart surgery –a TAVI. ( transcatheter aortic valve implantation) Extra info – www.papworthhospital.nhs.

Slide 6: George returns to his GP with his wife. Image of George, his wife and GP. His GP alleviates his fears and explains why the TAVI is not necessarily the best option and together they decide to have

A. BAVP.

B. MAVP.

George decides on the mechanical valve as he does not want to risk going through an operation again.

For more information:

• Heart Valve Voice
• BHF: Heart valve disease
• Medtronic: Treatment options for heart valve disease

Slide 7: 2 months after George’s surgery and valve replacement: George returns to the cardiology clinic where he reports that his breathlessness is so much better and he is thinking about going back to work. Image of George and cardiologist. He has been attending cardiac rehabilitation class. A repeat echo shows the new valve is working well and his heart function is much better. George will need to see the cardiologist and have review echos every year. He will have to have regular blood tests – INR.

Slide 8: Image of George and his wife on bikes.