aortic valve stenosis

My brother-in-law is a 73 year old patient with a complicated medical history
He has had a triple bypass, has glomernephritis with a high (3.5) creatin level, emphysema (COPD) as well as pulmonary effusion, and a deteriorating neurological condition (MS or similar) so for the last 2 years he has been wheelchair bound. He is on oxygen.

His body weight is @ 145lbs -ten lbs due to water retention  (height about 6 feet)

He was admitted to Delray Beach Medical Center on Saturday with Congestive heart failure and fluid around his heart and lungs.  He is on quadruple lassix dosage and his kidney output has increased. They can't due a catheterization because of kidney pulmonary effusion.

Today the hospital did a test to see at what level his aortic valve was functioning.  We think his aortic valve function is down to 38%-39% gradient?
They plan to do  a needle aspiration of the lungs to try and determine the content of the fluid and possibly an esophageal cardiogram to check the functioning of the aortic valve.  

The cardiologist does not think he would be a candidate for aortic valve replacement because of all the compicating conditions and his current weakened state.  Articles we have read on line seem to indicate that an angioplasty in an older patient with stenosis is not reccommended.

What type of doctor(s) should be monitoring this patient?
What questions should we be asking ?
What direction should we be taking ?
I realize these are extensive questions and I may not have all the facts in order but any help you can provide would be greatly appreciated.  

[Jack54]

So sorry to hear about you BIL. He needs to be seen by a cardiologist, pulmonologist and nephrologist at least.

You should be asking if he is being treated with all of the right drugs for sure and what is the ejection fraction of his heart. This was more than likely determined when the test was done to determine the status of his aortic valve. This was probably an echocardiogram. The 38%-39% gradient you mention is a pressure gradient (pressure drop or loss due to the stenotic aortic valve) measured or taken from the difference in the left ventricle output pressure versus the pressure on the far side of the aortic valve. The pressure gradient should be 0.

His ejection fraction is the most important number for the family to know at this point. This fraction, which is normally between ~55-70 in a healthy person, shows how well his heart is performing. If it is really low it means his cardiac output is low and this in and of itself will cause fluid to continue to build up. The heart pumps ~1/3 of it's total output through the kidneys where excess fluid is filtered out by the kidneys. If the output of the heart is low, there is poor filtering and fluid retention. He should have absolutely no salt and I am sure the caregivers are watching his intake of fluids. His blood electrolyte levels need to be watch closely.

Sometimes the ejection fraction can be misleading in certain types of heart failure, such as diastolic heart failure. You could ask the cardiologist if his EF is real as opposed to preserved. The echocardiogram also gives results on the size of the dimensions of his heart and the status of his other 3 valves. You should also ask if the aortic valve is only stenotic, or if there is also leakage involved.

The Lasix he is taking will deplete is potassium quickly and cause hypokalemia, which can be lethal. He will have to have large doses of prescription potassium.

He is a perfect candidate for the 64 slice Coronary Artery CT Scan, it seems to me. I have read that underweight, elderly people are at the highest risk for cardiac catheterizations. I have had the 64 Slice scan and it was 100% correct as verified by a followup cath and stent. I have had 10 cardiac caths....It seems medicare should pay for this scan, given the circumstances. If not, the test are under $1000.

I wish your BIL the very best. The road ahead looks tough, but doctors can do amazing things nowadays.

Jack

[dianepro]

Thank you for your detailed response and good luck with your own road to recovery.  
By any chance - di you have your CT Scan done in South FLorida - we're looking for a thoracic surgeon or intervention cardiologist.
Thanks again

[Jack54]

Thanks for the well wishes :)

I had my scan done in Alabama. The best way to find a surgeon or cardiologist with great credentials, is to go to the web site(s) of the hospital(s) that you plan to use. Then click on their physician finder tab, and most times it gives the colleges attended and all board certifications for all doctors associated with the hospital. Also listed is their areas of interest, sometimes.

You can also go to the American Medical Association's web site and they have a physician lookup. It the physician is not a member of the AMA, the background info will be limited.

Best of luck and health :)

Jack

[dianepro]

Thanks Jack