Case of Refractory Hypertension Controlled After Surgical Intervention

Case of Refractory Hypertension Controlled After Surgical Intervention

Case of Refractory Hypertension Controlled After Surgical Intervention

Title: Case of Refractory Hypertension: Controlled after Aortic, Mitral Valve Replacement and Coronary Artery Bypass Grafting
Description: Refractory Hypertension Controlled after Aortic, Mitral Valve Replacement and Coronary Artery Bypass Grafting. Presented by Dr. Mohammed Siddiqui and Dr. David Calhoun at the AHA Council on Hypertension | AHA Council on Kidney in Cardiovascular Disease | American Society of Hypertension Joint Scientific Sessions 2017 as part of a Clinical-Pathological conference session sponsored by Hypertension, an American Heart Association journal. Filmed 16 September 2017. The case focuses on a 78-year-old black man in the care of the Cardiology-Hypertension clinic at University of Alabama at Birmingham for uncontrolled blood pressure since August 2011.


Content

0.1 -> Our next speaker is Dr. Mohammed Siddiqui from UAB,
5.071 -> mentored by David Calhoun.
7.273 -> And this is a case of refractory hypertension
9.809 -> that was miraculously controlled after aortic
13.747 -> and mitral valve replacement and coronary bypass grafting.
16.816 -> So acclaim for the surgeons, I guess.
19.352 -> And Siddiqui will explain the pathogenesis.
24.657 -> Good morning.
25.525 -> Thank you for inviting us for do this CBC.
28.628 -> So we have a case of refractory hypertension
31.231 -> controlled after aortic and mitral valve replacement and
34.701 -> coronary artery bypass grafting.
40.507 -> So me, along with Dr. Calhoun, will be presenting this case.
46.246 -> So we had a 38-year old African-American man who came
50.45 -> to hypertension clinic at University of Alabama at
53.353 -> Birmingham for uncontrolled blood pressure.
55.588 -> And he was first seen in August 2011.
59.492 -> So his blood pressure was always uncontrolled.
61.961 -> So we have a timeline of his blood pressure
64.164 -> from 2011 to 2016.
66.499 -> And his systolic blood pressure was around 150,
70.437 -> more than 150.
71.571 -> Diastolic blood pressure was around 80s,
73.373 -> but systolic was high.
75.809 -> So an average systolic blood pressure over these years was
82.248 -> around 167 and diastolic was in 80s.
88.555 -> So the mean arterial pressure was high too, in hundreds.
95.128 -> So this is a case of refractory hypertension.
99.265 -> Refractory hypertension is recently been evaluated as a
103.703 -> phenotype of antihypertensive treatment failure.
107.474 -> And we, along with couple of other centers,
111.244 -> have been working on these studies.
113.146 -> Dr. Calhoun is my mentor, who does refractory hypertension,
118.952 -> and if he would like to talk about it.
123.089 -> Yeah, I just wanna ... We are very interested in
126.192 -> these cases of really antihypertensive failure.
129.629 -> And, so, we have ongoing protocol where we are trying
134.4 -> to characterize these patients.
135.835 -> So I just want to sort of give you that context of what we're
139.405 -> thinking about in general about these patients.
141.708 -> So, obviously, patients are referred to us for
143.676 -> uncontrolled hypertension.
145.411 -> We'll try to confirm their blood pressure,
150.049 -> usually with out-of-office blood pressures we can't...
152.519 -> don't do ambulatory monitoring on everybody,
154.988 -> just out of convenience.
156.456 -> But confirm their out-of-office high blood pressures.
160.527 -> Our treatment approach, I think, like most of us,
163.463 -> is gonna be- initially, is a triple combination of:
166.065 -> a RAS blocker, calcium channel blocker (in our clinic is
170.803 -> almost always Amlodipine) and then patients are typically
174.507 -> referred to us on hydrochlorothiazide,
176.376 -> and some of the earliest changes we make is switching
179.279 -> them from hydrochlorothiazide to the Chlorthalidone.
182.115 -> So, that's, sort of, our standard triple regimen.
185.618 -> We do screen them for secondary causes.
191.257 -> In our clinic, we get - patients with resistant
195.929 -> hypertension - we'll get a 24-hour urine on all of them,
199.132 -> looking at sodium, protein, cortisol and aldosterone.
201.968 -> And, obviously, get an aldosterone-renin ratio as well.
205.505 -> If there's a high level of suspicion,
208.207 -> we'll screen them for renal artery stenosis by doppler,
211.444 -> and then easily screen them for Pheo by metanephrines.
216.082 -> As a fourth agent, we'll add Spironolactone.
221.187 -> And then, after that, it's sort of individualized.
224.223 -> Or we typically will add a combined alpha-beta blocker.
227.327 -> We typically use Labetalol, mostly,
229.963 -> as opposed to Carvedilol.
231.931 -> At least, we prefer to because of the wider dose range.
235.501 -> We can get to much higher doses,
237.036 -> which I think is more effective.
238.605 -> We're, sort of, forced into using Carvedilol more often
241.541 -> now because it's less expensive,
245.311 -> so often preferred by insurance companies.
248.581 -> And after that, we may add a centrally-acting agent.
252.385 -> We do use Guanfacine, doesn't do a lot.
255.221 -> At least it's once a day.
256.956 -> We'll try to use a Clonidine patch, but also expensive.
261.027 -> Then, lastly, add a vasodilator - hydralazine.
264.13 -> Again, we confirm out-of-office blood pressure.
267.233 -> They spend a lot of time teaching patients how to
268.835 -> measure their blood pressure, encourage them to obtain a
272.939 -> home blood pressure monitor, and if we can,
274.607 -> do the inventory monitoring.
276.876 -> And then, obviously, trying to exclude white coat.
280.813 -> And then, lastly, adherence is going to be an important
286.185 -> issue in all these cases, in this patient as well.
288.321 -> So we will, obviously, try to get an assessment by
294.961 -> self-report, pill counts if we can.
298.564 -> We do ask them to bring in their pill bottles at each
300.833 -> visit, and look at refill rates online, now,
303.336 -> more and more electronically.
304.771 -> We do have an ongoing collaboration measuring
309.008 -> urinary metabolites, but it takes a while,
313.179 -> so that's not clinically available on
317.417 -> a case-by-case basis.
319.786 -> So, I'll let Dr. Siddiqui take over now in terms of the
322.522 -> individual situation of this patient.
331.597 -> So, since 2011, the patient, when he first showed up at our
336.135 -> clinic, he was on three blood pressure medications:
338.104 -> an ARB, a calcium channel blocker,
340.239 -> and a thiazide diuretic.
341.574 -> And then he was added a spironolactone.
346.179 -> Then, eventually, he was added on a hydralazine,
349.682 -> a vasodilator.
351.25 -> And then the sixth agent was Clonidine.
353.386 -> So, this patient was uncontrolled on six blood
358.024 -> pressure medications.
358.858 -> So, this was his blood pressures: systolic blood
362.395 -> pressure is high, and this was the gradual increase in blood
366.866 -> pressure medication, so over the years from 2011 to '16.
371.27 -> So, the GFR - the kidney function was good,
377.877 -> it was stable.
378.578 -> GFR was around 55- more than 60 over these years.
382.548 -> The average of creatinine over the years was around 1.35.
389.722 -> So, we evaluated for secondary causes of high
395.094 -> blood pressure, and the other conditions that might be
399.098 -> related to high blood pressure.
400.767 -> So, here, the normal HbA1c, so diabetes was excluded.
407.039 -> The secondary causes of hypertension were excluded by
410.109 -> doing a renal doppler.
411.844 -> He did not have any renal artery stenosis.
415.181 -> He had a normal aldosterone, a normal plasma renin,
418.918 -> so hyperaldosteronism primary and secondary was excluded.
424.257 -> And he had a normal catecholamines and
426.459 -> metanephrines, so Pheochromocytoma
428.127 -> was excluded, too.
429.428 -> So, the other co-morbidities he had,
433.266 -> along with high blood pressure,
434.534 -> was he had a mitral valve regurgitation.
437.336 -> So, he had a Myxomatous/thickened mitral
440.54 -> valve, which was dilated.
443.543 -> The annulus was dilated 5 cm.
447.313 -> So, he had a moderate to severe mitral regurgitation,
451.45 -> and the jet was posteriorly directed,
456.489 -> which caused the systolic retrograde flow in the right
459.325 -> pulmonary vein.
461.16 -> The E/A ratio was 1.5.
464.897 -> I have a video of the echo, I'm not sure how to play this.
474.307 -> So, I'll just skip over to the next slide.
477.643 -> So, along with the mitral valve regurgitation,
479.912 -> he had aortic valve insufficiency.
482.181 -> He had a thick aortic valve, he had moderate to severe
486.919 -> aortic insufficiency.
489.155 -> The jet was eccentrically directed towards the anterior
494.36 -> mitral valve leaflet, and these are the echo videos,
501.167 -> which shows the blood backflow.
505.338 -> So, what is the interaction of hypertension and aortic
509.642 -> valve insufficiency?
511.577 -> Systolic hypertension causes increased wall stress,
516.515 -> increasing left ventricular volume to mass ratio.
521.52 -> The left ventricle adapts to the volume of the load with
525.291 -> increasing end-diastolic volume, increased compliance,
528.494 -> and increased hypertrophy.
530.93 -> Which causes the prolonged asymptomatic stability in
535.067 -> these patients.
537.203 -> There's an increase in compensatory preload,
539.505 -> and a decrease in pressure volume relationship
542.942 -> or elastance.
547.58 -> When the limits of compensation are reached,
549.782 -> it increases the wall stress, and causes myocardial
554.287 -> dysfunction and systolic failure.
556.689 -> And simultaneously, there's left ventricular hypertrophy
559.725 -> and fibrosis, causing diastolic dysfunction.
563.529 -> And these symptoms include those of heart failure
567.033 -> and angina.
569.168 -> So, what is the management in patients with hypertension and
577.243 -> aortic valve insufficiency?
578.477 -> According to the AHA/ACC guidelines,
581.18 -> the treatment of hypertensive patients who have chronic
585.718 -> aortic regurgitation, the systolic blood pressure should
587.987 -> be maintained above 140, that's stage B progressive AR
591.457 -> and stage C (asymptomatic severe AR).
594.827 -> The medications used here are Dihydropyridine calcium
599.598 -> channel blockers, or Angiotensin-converting enzyme
603.97 -> inhibitor (ACE), or angiotensin receptor blocker (ARB).
609.241 -> This is 2014 guidelines.
612.712 -> The echocardiographic findings in this patient:
615.948 -> This patient had a normal left ventricular systolic function,
620.82 -> but a severe left ventricular dilation,
624.457 -> and the ejection fraction was around 50 to 55 over these
628.828 -> years, stable, and he had a tricuspid regurgitation,
634.4 -> and pulmonary regurgitation, too.
637.636 -> So, here is the patient, he had a stroke volume
643.409 -> which was high, it was 97.
649.382 -> So, besides the mitral regurgitation and aortic
655.421 -> insufficiency, he also had a coronary artery disease.
659.792 -> So, left and right heart cath were done.
662.395 -> The left main artery had a 60% stenosis,
666.232 -> the left anterior descending artery had an 80% proximal
673.105 -> stenosis and a 60% distal stenosis.
676.342 -> The left circumflex artery had a 40% calcified stenosis.
682.815 -> Besides that, right coronary artery had 80% stenosis and
689.021 -> posterior descending artery had 60% stenosis.
696.095 -> So, the left and right cath were done.
699.131 -> The right atrial pressure was 12, which was high.
702.101 -> The pulmonary artery pressure was high, too.
704.703 -> The mean pressure gradient was high,
707.173 -> and the pulmonary capillary wedge pressure was high.
710.91 -> So, again, a video.
713.913 -> So, what would be the management in patient with
718.217 -> hypertension-coronary artery disease?
720.886 -> So, the blood pressure should be targeted below 140/90mm,
725.458 -> should be below.
728.194 -> And the management for high blood pressure and coronary
731.864 -> artery disease is either beta-blocker,
734.967 -> calcium-channel blocker, ACE and ARB,
738.671 -> thiazide and nitrates.
741.974 -> So, this is according to the guidelines.
745.01 -> So, to summarize, we had refractory hypertension
748.781 -> patient who was uncontrolled blood pressure.
751.851 -> We did automated office blood pressure,
755.488 -> which was more than 135/85.
758.757 -> He was on six high blood pressure medications,
761.026 -> including an ARB, calcium-channel blocker,
763.262 -> thiazide, mineralocorticoid antagonist,
766.866 -> vasodilator and centrally acting agent Clonidine.
771.17 -> Secondary causes of hypertension were excluded.
774.273 -> There was no renal artery stenosis,
776.242 -> there was no hyperaldosteronism,
778.31 -> there was no pheochromocytoma.
780.513 -> He was non-diabetic, had a moderate to severe mitral
784.25 -> regurgitation, moderate to severe aortic insufficiency,
788.254 -> and a coronary artery disease.
791.924 -> So, I would, if any audience wants to pitch in.
800.666 -> They are all coming to microphones,
802.501 -> there is lots of -(laughs) comments.
805.804 -> -lots of speakers.
807.806 -> This is a very interesting case.
810.943 -> And I'd like to go back to the average systolic and diastolic
816.348 -> blood pressures in the office.
818.217 -> So, it looked to me like this was predominantly systolic
822.321 -> hypertension and there was a relatively
824.757 -> low diastolic pressure.
827.96 -> And I'd like us all to reflect that in this patient
831.73 -> who has major coronary atherosclerotic disease,
836.936 -> this patient may be at risk for a myocardial infarction
842.908 -> when the diastolic pressure drops below filling pressure.
847.78 -> So, one has to be very careful and walk a tight line here
853.552 -> until definitive therapy is achieved.
859.091 -> Hi, Rob Phillips.
860.125 -> So, with this particular person,
862.595 -> even though the guidelines give the opportunity to use
865.698 -> beta-blockers, I would not do that in him.
868.767 -> I wouldn't give him all that time for filling.
871.57 -> I mean, you're really giving him time to raise his left
874.873 -> ventricular and diastolic pressure with all that aortic
877.61 -> insufficiency and he's already demonstrating that he's not
882.781 -> able to tolerate that, with regard to diastolic function.
886.852 -> So, that's one thing which I just wanted to- I would
892.358 -> operate on my- as a cardiologist in a very
895.294 -> surgical hospital, Houston Methodist,
897.596 -> the home of- still the ghost of Michael DeBakey,
900.332 -> I would've probably had him in the OR a couple days ago.
908.974 -> I would like to have a- I have an issue with the need for
916.882 -> some of the secondary hypertension work-up.
919.918 -> If someone takes an ACE inhibitor or ARB,
923.022 -> as this patient did, and has severe hypertension,
927.426 -> the likelihood that the finding of [inaudible]
930.095 -> atherostenosis will lead to any helpful therapeutic action
938.103 -> is nul, given that this is the best prediction
944.109 -> of renal [inaudible].
948.714 -> Pheochromocytoma is extremely rare, in general,
953.452 -> and in particular at the age of 78,
956.322 -> in someone whose hypertension is somewhat justified and,
962.061 -> I think, this is not helpful, secondary [inaudible] is
966.632 -> certainly something that is important in this patient.
971.403 -> I would like also to have, if I may, a word,
976.041 -> in terms of what are the benefits of adding Hydralazine
980.012 -> to a high dose of Amlodipine.
984.516 -> Some, I think, 30 years ago, when Nifedipine was an
990.622 -> emerging product, my colleagues and myself have found,
995.194 -> as many others, that 30 mg of Nifedipine surpasses the
1002.634 -> anti-hypertensive efficacy of 200 mg of Hydralazine.
1010.709 -> So, I think, in this context, Minoxidil,
1014.446 -> and then eliminating Amlodipine because, anyway,
1018.517 -> these drugs accumulate, might have been a better choice,
1026.158 -> given that he is taking beta-blocker anyway,
1029.261 -> and he's taking the diuretic anyway,
1030.996 -> so some of the expected side effects of Minoxidil
1038.07 -> can be counteracted.
1040.672 -> Yeah, that's exactly in the hours- the reason for
1045.11 -> presenting the case at this point, was,
1046.612 -> "How might we have done better?"
1047.813 -> In terms of, obviously we weren't controlling his blood
1049.715 -> pressure at this point, in spite of the six medications,
1052.618 -> so we were looking for feedback in terms of what we
1055.387 -> might have done differently.
1056.922 -> I mean, just anecdotally, we do see additional benefit
1059.158 -> adding Hydralazine to a dihydropyridine calcium
1063.362 -> channel blocker, in terms of blood pressure,
1065.097 -> so that's routinely done, certainly in our clinic.
1068.5 -> So, if the patient is failing, dihydropyridine,
1071.537 -> though, in terms of blood pressure and a vasodilator,
1073.672 -> so, again, our question was, "What might we have done
1078.677 -> differently, at this point, in terms of blood pressure
1080.779 -> management?"
1081.146 -> But, before we get to the sort of abrupt resolution,
1084.383 -> if you will, I think Dom has already told us last night
1088.353 -> what we should have been doing.
1091.39 -> I think, echoing the comments, I think one has to be quite
1095.127 -> careful with filling pressures here.
1096.995 -> So, comment number one would be, is,
1099.431 -> "How do you diurese a patient in this current situation,
1102.367 -> and do you change filling pressures too much with
1105.804 -> over-diuresis and, therefore, worsen the situation?"
1109.575 -> I'm sure that went through your mind there.
1111.877 -> Item two would have been a trial of isosorbide
1114.513 -> mononitrate or dinitrate while the patient's in clinic,
1118.116 -> to see what the hemodynamic changes were with
1120.385 -> the nitrate therapy.
1121.987 -> Nitrate therapy may be unusable,
1124.223 -> it looks like there was fixed coronary lesions here,
1126.592 -> calcific in nature, so you may not have had a great response,
1129.962 -> but that is one of our hidden sources of therapies in
1135.801 -> resistant hypertension, are nitrates.
1138.17 -> Third issue would be whether or not the person had any
1142.341 -> vestige or hint of sleep apnea,
1144.61 -> which may have explained some of the right-sided pressures,
1147.212 -> although this certainly fit with the left-sided phenomenon
1149.648 -> that are there.
1150.816 -> And the fourth thing would be,
1152.584 -> "What would happen if we switched the patient from a
1155.22 -> dihydropyridine to a non-dihydropyridine and tried
1158.257 -> to use Diltiazem to see what the hemodynamic change would be,
1161.026 -> starting with a low dose and working upward from there?"
1163.762 -> The hemodynamics, looking at it,
1166.732 -> I guess the EF was between 50 and 55 percent,
1169.568 -> so you have a little bit of margin for EF suppression,
1172.838 -> but the dynamics with Dilt, for example,
1176.108 -> might be a little bit different than the dynamics
1177.643 -> with Nifedipine.
1178.977 -> That being said, echoing Dr. Phillips' comments,
1183.248 -> if in Richmond, the patient would've been in the
1185.217 -> OR yesterday.
1186.718 -> So, would you have considered adding Diltiazem to the
1191.89 -> dihydropiridine instead of substituting?
1194.693 -> Yeah, I think the only problem with Dilt is when we run the
1197.863 -> medicine list and we look for CYP3A4-metabolized drugs,
1201.6 -> it's a potent CYP3A4 inhibitor,
1203.802 -> so at a dose of 240 mg of sustained-release Dilt,
1208.307 -> your AUC for simvastatin, for example,
1210.776 -> or simvastatic acid will go up three-fold.
1212.978 -> So, you almost have to run the list,
1214.746 -> understanding that you may upset the apple cart,
1217.316 -> so to speak, with the CYP3A4 inhibitor being put there.
1220.419 -> But the CYP3A4 inhibitor, I guess the patient was on
1223.455 -> Nifedipine, is that correct?
1226.091 -> Was in Nifedipine or Amlodipine?
1227.092 -> Amlodipine. Amlodipine.
1228.193 -> Yeah, that's CYP3A4-metabolized,
1230.429 -> so you ramp up the blood levels of Amlodipine,
1233.031 -> concurrent with having a different calcium channel
1235.834 -> blocker type by using the Diltiazem.
1238.57 -> But I think these are all just measures where you're trying
1243.008 -> to get the right fix or the right amount of drug, but,
1247.112 -> unfortunately, until there's surgical intervention,
1249.748 -> you can't quite figure out what [inaudible] on.
1252.25 -> And the question is, "Why do you get a derivative product
1254.72 -> of hypertension with this kind of cardiac pathology?"
1258.023 -> Presuming it be either modest cardiac ischemia,
1263.328 -> and/or changes in contractility.
1266.365 -> So, you've got very hyperdynamic precordium on
1269.601 -> physical exam, and hyperdynamic set of values,
1272.971 -> so changing from hyperdynamic to more isodynamic in nature
1277.342 -> sometimes can help the blood pressure,
1279.077 -> but by no means are you ever going to correct it in this
1281.346 -> type of patient without surgery.
1287.853 -> Hi. Goldman, Philadelphia.
1289.521 -> David, I really appreciate that you're bringing attention
1292.09 -> to refractory hypertension.
1294.126 -> I actually had a poster at the ASH meeting about three or
1298.03 -> four years ago, where we had really reached this extreme
1303.669 -> level of not knowing how to- my patient did not have the
1307.939 -> aortic valvular disease, but we did notice that every time
1312.778 -> they would wind up in the CCU with hypertensive urgency,
1318.517 -> they seemed to be controllable with parenteral Nicardipine.
1324.322 -> So, we created the fairly novel approach of sending her
1329.561 -> home on an IV Nicardipine infusion just like- and you'd
1336.935 -> be surprised- just like patients get home Milrinone.
1340.405 -> And I must tell you, it was fairly successful.
1344.476 -> She ended up ultimately going on dialysis and transferring
1349.648 -> to another facility, but it was out of desperation
1353.485 -> we really did try that.
1358.757 -> Thank you very much for sharing this case.
1360.892 -> I'm Vik Selva from Cambridge.
1362.127 -> Just two points: one is pathophysiology.
1365.097 -> Can I just ask if you think that the aortic regurgitation
1370.068 -> here is secondary to aortic dilatation in the context
1373.905 -> of hypertension?
1375.207 -> This guy has a chronic hypertentive resistant disease.
1377.943 -> Because in Cambridge, we see a lot of resistant hypertension,
1380.545 -> and we see a number of them with aortic regurg,
1383.448 -> and we think this is a secondary phenomenon.
1385.917 -> We also notice this is more common in people of black race.
1388.854 -> They have more cardiac effects of hypertension.
1390.822 -> That's my first question.
1391.99 -> Second is a bit more practical.
1393.391 -> In terms of expanding therapy, I know the licensed dose of
1396.762 -> Amlodipine, the highest is 10 mg.
1399.664 -> What we do, and may be considered,
1402.167 -> is switching them to Nifedipine [inaudible] mg,
1406.071 -> which is the equivalent dose, and up-titrating it in
1409.241 -> patients of black race.
1410.142 -> That seems to be something that's quite effective.
1413.311 -> Thanks.
1414.913 -> Yeah, in terms of the second comment,
1417.315 -> I think I would agree.
1418.35 -> I think Nifedipine, probably at the highest dose,
1420.719 -> is a superior antihypertensive to Amlodipine.
1424.289 -> It's just, again, we're restricted.
1426.558 -> Amlodipine is usually preferred by most of our
1431.863 -> insurance companies in terms of their tier system,
1434.166 -> whereas Nifedipine XL is not, and so we can be limited
1438.703 -> because of that choice.
1440.405 -> I think, in terms of the first question,
1442.073 -> there's certainly- we're not, obviously,
1446.077 -> going to know for sure, but it's probably a combination of
1449.881 -> the high blood pressure in the regurg as well as the
1455.187 -> underlying anatomic abnormality,
1457.889 -> in terms of the aortic valve, I suspect is a, sort of,
1460.292 -> a combination.
1462.227 -> Okay.
1462.828 -> We need to hear more.
1466.364 -> So, moving forward.
1467.499 -> So, this patient had acute hospital admission on
1472.704 -> September 6th, 2016.
1474.172 -> The patient was admitted for worsening shortness of breath,
1477.042 -> dyspnea on exertion, orthopnea, PND,
1479.711 -> mild productive cough, abdominal discomfort on
1483.982 -> distention, urinary frequency and acute-on-chronic leg edema.
1490.188 -> So, the blood pressure on admission was 224/77.
1494.893 -> Heart rate was 110.
1497.362 -> And BNP was elevated - 1899, and the [inaudible] were
1503.969 -> elevated, too.
1506.538 -> So, he was admitted and they did a cath,
1512.01 -> and they did echoes, and then the patient agreed to have a
1516.748 -> surgery for mitral valve replacement.
1521.586 -> So, he had a moderate to severe mitral regurgitation,
1526.725 -> and he had a anterior mitral vale leaflet prolapse,
1530.695 -> and the jet was posteriorly directed.
1534.299 -> So, he had a procedure where mitral valve was placed
1538.27 -> (a bioprosthetic valve) and post-procedure,
1543.975 -> the valve was well seated, it was functionally good,
1546.811 -> he did not have any mitral regurgitation.
1550.582 -> Along with the mitral valve replacement, he also- So,
1554.419 -> these are the echocardiographic values
1559.19 -> before the surgery, taken.
1562.227 -> Mitral valve: severe- moderate to severe mitral regurgitation.
1568.6 -> This is the echo four days after surgery.
1577.409 -> He had a bioprosthetic mitral valve.
1579.277 -> No regurgitation.
1580.946 -> His E/A was 1.5 before the surgery,
1583.682 -> but kind of increased to 1.9.
1586.184 -> But after the surgery, after two weeks it came down.
1590.588 -> And this is the echo after the surgery.
1593.358 -> So, along with the mitral valve replacement,
1596.428 -> he also had aortic valve replacement.
1598.53 -> So, he does have moderate to severe aortic insufficiency.
1604.202 -> So, pre-procedural echo showed jet of regurgitation directed
1611.476 -> towards the anterior mitral valve leaflet.
1614.379 -> The procedure was aortic valve replacement,
1617.716 -> a bioprosthetic valve, which was placed in the aortic position.
1621.786 -> And after the procedure, the post-procedural echo,
1625.623 -> the valve was well seated, it was functionally good,
1628.793 -> and the patient did not have any mitral insufficiency.
1634.432 -> So, the echo findings before and after aortic valve replacement.
1638.87 -> So, thick aortic valve, moderate to severe aortic
1643.008 -> regurgitation before surgery.
1645.21 -> This was the echo.
1646.711 -> And after the surgery, echo after four days,
1651.082 -> he did not have aortic regurgitation.
1653.685 -> And, similar echo after two weeks.
1656.554 -> And did not have any aortic and mitral valve regurgitation.
1661.893 -> So, the other echocardiographic findings before and after
1668.166 -> surgery: so, here,
1670.568 -> the severe left ventricular dilation that was obvious.
1675.673 -> And his systolic function was normal,
1678.543 -> his ejection fraction was around 50 to 55,
1681.913 -> that was before surgery.
1683.715 -> And after surgery, his LV dilation was moderate - that
1688.153 -> was four days after surgery.
1689.587 -> And the left ventricular systolic function kind of
1693.024 -> decreased after surgery.
1694.659 -> The ejection fraction was 30 to 35 but improved in two
1698.73 -> weeks and it was again back to 55.
1701.399 -> But the LV dilation, which was [inaudible] after the surgery,
1705.87 -> was borderline to minimum, and the systolic function
1709.34 -> improved, too.
1711.943 -> And the other findings with the right atrial size,
1714.646 -> the right ventricle function, everything was normal.
1719.651 -> So, along with this mitral valve replacement,
1724.122 -> aortic valve replacement, he also had a coronary artery
1727.659 -> bypass grafting.
1728.96 -> So, as previously mentioned, the pre-procedural cath showed
1732.964 -> a stenosis in left main artery,
1735.366 -> left anterior descending artery,
1737.202 -> left circumflex artery, right coronary artery,
1740.738 -> posterior descending artery.
1742.707 -> So, the procedure was done, coronary artery bypass
1746.044 -> grafting was done.
1747.545 -> Left internal thoracic artery graft to LAD and [inaudible]
1753.818 -> vein graft to PDA.
1757.088 -> So, if anybody has comments.
1763.061 -> Rob Phillips again.
1764.129 -> The only thing I would add to the case with the
1766.197 -> echocardiography is to put in the values for
1769.601 -> the tissue doppler.
1770.902 -> Because, in the original echo, it looks like he might have a
1774.739 -> pseudo-restrictive pattern.
1776.441 -> You would expect that to go away with the surgery.
1779.444 -> But it's very helpful to have the tissue doppler values in
1783.014 -> there as well, so you can follow those over time.
1785.116 -> Sure, will do.
1785.617 -> Thank you.
1787.418 -> So, the blood pressure before and after the surgery.
1790.488 -> So, as we know, he had a consistently higher systolic
1794.058 -> blood pressure above 150, and diastolic blood pressure was
1798.563 -> normal, so if you can see, after surgery,
1802.6 -> his systolic blood pressure dropped to 120.
1806.07 -> Let me zoom in there.
1808.84 -> So, this is the blood pressure before the surgery,
1813.545 -> and this is after surgery.
1816.181 -> So, the mean blood pressure, before surgery,
1818.283 -> was in 160s and after surgery, his systolic blood pressure
1822.72 -> dropped to 119.
1824.956 -> And this is the average after surgery,
1826.791 -> and this is the average of one year.
1829.093 -> And there was no change in diastolic blood pressure.
1832.797 -> And it was in the 80s before and after the surgery.
1839.137 -> [crosstalk] medicine.
1840.171 -> Medication? No medicine [crosstalk].
1840.972 -> Yeah, I'll go over it.
1842.106 -> So, the mean arterial pressure before and after the surgery
1845.276 -> was- mean arterial pressure was high,
1847.378 -> and after surgery was- so, just to zoom in,
1850.949 -> and was reduced to 85.
1853.685 -> So, what happened to these medications after surgery?
1857.555 -> So, as we know, he was on six blood pressure medications
1860.792 -> over the years, so he was on a ARB,
1865.797 -> a calcium channel blocker, a thiazide, a spironolactone,
1870.235 -> hydralazine, and clonidine.
1871.703 -> That was before surgery.
1873.504 -> So, after surgery, for a month or two,
1878.676 -> he was on no medications.
1880.445 -> He was on zero medications, his blood pressure was in 120s.
1883.982 -> And, eventually, he was added Amlodipine 5 mg by the
1888.953 -> cardiologist, and then later on he was added the spironolactone.
1895.193 -> So, the blood pressure response,
1898.062 -> along with the medications, so the timeline, if you can see,
1903.768 -> there was no change in the blood pressure when all these
1906.604 -> medications were added, but after the surgery,
1909.44 -> he was not on any blood pressure medication,
1912.01 -> but eventually he got on one, and then on the spironolactone,
1916.247 -> second blood pressure medication.
1919.183 -> So, what would be the possible mechanism?
1923.354 -> I mean, the first possible mechanism we want to look into
1927.292 -> is medication adherence.
1929.193 -> Maybe was he not taking all his blood pressure
1931.329 -> medications, and after surgery, well,
1934.866 -> he had a change of heart, and then he started taking blood
1937.669 -> pressure medications.
1938.936 -> Well, if we think that he was, we checked his blood pressure
1946.678 -> medication adherence, we see them verbally,
1950.315 -> he said he was taking all his blood pressure medications,
1952.817 -> we checked- they bring the pill bottles, we checked that.
1956.387 -> And we checked the refill authorization at the pharmacy,
1960.158 -> and he was actually refilling all
1961.793 -> his blood pressure medication.
1964.362 -> It was a few years back, and we did not do any urine
1970.601 -> testing for drug metabolites in this patient.
1974.339 -> So, the medication adherence probably would not have played
1977.842 -> a role here, because, I mean, maybe,
1981.112 -> let's say if he was on zero blood pressure medications,
1983.448 -> he was not taking any medication and his blood
1985.316 -> pressure was in 160s, and even after the surgery,
1989.887 -> for a few months, he was not on any medication and his
1993.224 -> blood pressure was in 120s, so probably that might rule out
1997.495 -> any medication non-compliance in this patient.
2002.6 -> So, what happened to the weight, BMI.
2006.771 -> So, the weight was stable during those years,
2009.507 -> even after surgery he did not lose any weight.
2012.543 -> So, blood pressure does go down with weight reduction.
2017.482 -> So, there was no change in weight,
2019.817 -> and there was no change in the BMI before
2022.387 -> and after the surgery.
2026.023 -> So, we rule out any mechanism that weight reduction may have
2031.295 -> played any role in blood pressure reduction
2033.798 -> in this patient.
2035.833 -> So, GFR, serum creatinine before and after the surgery.
2039.437 -> GFR was stable, and after the surgery, it went down and,
2044.976 -> again, improved in a month.
2048.679 -> Creatinine was stable in 1.35 and after the surgery,
2052.784 -> creatinine went up to 2.5.
2054.886 -> He had a AKI.
2056.721 -> We have to exclude out if it was acute tubular necrosis,
2060.691 -> but he did have an AKI.
2062.86 -> And then the creatinine came back to normal.
2067.131 -> So, this is the zoom in where his GFR went down and
2072.837 -> improved, and this was the creatinine.
2076.207 -> And before the surgery, his creatinine was stable,
2079.544 -> and after the surgery, excluding the high creatinine,
2083.047 -> it was similar, but I've included here,
2085.349 -> so it looks a little bit more than
2087.685 -> the pre-procedural creatinine.
2092.056 -> So, kidney function: so, there was decrease in systolic
2095.159 -> blood pressure around 40mm- 48mm reduction in systolic
2099.997 -> blood pressure.
2101.499 -> So, there was decreased kidney perfusion after surgery,
2104.402 -> and that decreased the kidney function.
2106.637 -> And, obviously, the kidney function improved back to
2109.807 -> normal in a month.
2111.509 -> So, he had the open heart surgery,
2114.679 -> and what about cardiac anesthesia?
2117.682 -> So, these are the medications, the cocktail of medications,
2123.488 -> given in cardiac anesthesia.
2125.423 -> So, does cardiac anesthesia reduce blood pressure?
2128.96 -> Well, it does, but not for a year.
2135.032 -> So, there is short-term blood pressure reduction after
2138.669 -> anesthesia, and it's a prolonged effect of anesthetic
2142.073 -> and pain medications they are given after the surgery.
2144.742 -> And there might be blood loss, there might be dehydration,
2148.412 -> heart problems, allergic reactions,
2150.882 -> and acute infection that might cause blood pressure reduction
2153.851 -> after surgery.
2155.186 -> But that's not prolonged for a year.
2158.523 -> And he had a coronary bypass grafting, too.
2162.994 -> So, CABG was done, and after CABG,
2172.136 -> there are multiple reasons why blood pressure goes up - due
2177.174 -> to pain, stress.
2178.943 -> And a few of the blood pressure medications after
2182.747 -> surgery will be discontinued, and then eventually,
2186.183 -> blood pressure goes up, and they are prescribed
2189.787 -> medications back again.
2191.489 -> But according to literature, blood pressure progressively
2196.861 -> increases in 24-hour and daytime systolic and diastolic
2200.765 -> pressures go up, up to 14 weeks after CABG.
2204.135 -> And nocturnal blood pressure dipping gets restored
2207.705 -> progressively, but in complete restoration after 14 weeks.
2212.043 -> And, parallelly, there is a complete restoration of
2215.212 -> sympathovagal balance.
2219.383 -> So, in certain patients, blood pressure do go down
2224.322 -> after CABG, but it does come back, I mean,
2228.292 -> they are back to the same blood pressure levels,
2231.429 -> pre-operatively, and then the blood pressure medications
2235.433 -> are introduced.
2238.502 -> So, aortic valve replacement, he had an aortic valve
2241.372 -> replacement.
2242.506 -> So, blood pressure changes are not predicted by the type
2245.076 -> of the valve inserted nor its size.
2247.912 -> Diastolic hypertension is prevalent, I mean,
2250.514 -> there's diastolic blood pressure increases after
2253.084 -> aortic valve replacement in aortic regurgitation patient.
2257.421 -> And there is a study on hypertension prevalence,
2260.858 -> and it showed that there is a decrease in blood pressure
2264.695 -> prevalence of 57% from 65% after aortic valve
2269.333 -> replacement in AI.
2271.002 -> But after a few weeks, they were hypertensive again.
2278.643 -> So, what we think would be the mechanism here is, well,
2286.017 -> everybody probably went through this equation
2290.121 -> when they were in the medical school.
2292.39 -> Mean arterial pressure is cardiac output and systemic
2295.059 -> vascular resistance, plus central venous pressures,
2298.896 -> which are minimum and they are normally not incorporated into
2303.701 -> the equation.
2305.703 -> So, cardiac output is stroke volume into heart rate.
2309.473 -> So, what happened to his heart rate after surgery?
2312.777 -> So, heart rate before surgery was stable, but after surgery,
2316.981 -> he did have intermittent AFib, but he was good on discharge.
2323.287 -> And there was no significant difference in heart rate
2327.358 -> before and after surgery.
2330.027 -> So, there was no drop in heart rate or increase in heart rate.
2334.799 -> And there was no change in heart rate,
2336.133 -> and heart rate would not have influenced the cardiac output,
2339.837 -> hence blood pressure here.
2341.639 -> Stroke volume, the other thing.
2344.341 -> So, his stroke volume was 97 before surgery,
2347.678 -> and after surgery, he had a massive reduction in stroke
2351.716 -> volume, to 47.
2354.819 -> So, there was no change in heart rate,
2358.456 -> the stroke volume decreased from 97 to 47 (a reduction in
2362.493 -> half) so that increased the cardiac output.
2366.63 -> The systemic vascular resistance does compensate,
2369.7 -> but it takes time, it's not a rapid process.
2375.372 -> So, this is before surgery.
2376.941 -> And after surgery, his stroke volume decreased,
2379.11 -> his cardiac output decreased, no change in heart rate.
2382.079 -> And that's the reason we think his blood pressure
2384.882 -> might have reduced.
2386.05 -> To summarize, we have a refractory hypertensive
2392.823 -> patient on six blood pressure medications.
2397.161 -> Systolic blood pressure is in 160s,
2400.264 -> he had a mitral valve replacement,
2402.666 -> an aortic valve replacement, and a CABG.
2407.838 -> And possible mechanisms we excluded was medication
2410.741 -> adherence, weight reduction, kidney aspects,
2415.045 -> cardiac anesthesia, mitral valve replacement,
2417.481 -> aortic valve replacement, and CABG.
2420.117 -> I mean, it was the aortic and mitral valve replacement
2423.053 -> that did the stroke volume, so, possibly the mechanism was
2427.591 -> the decrease in stroke volume.
2430.127 -> But we think it would not have been just the stroke volume,
2434.064 -> but a combination of things might have influenced the
2439.336 -> reduction in blood pressure from 167 to around 119.
2444.542 -> The stroke volume decreased, the cardiac output,
2447.111 -> no change in heart rate might have decreased
2449.28 -> the blood pressure.
2451.482 -> So, it's been a year since surgery.
2455.953 -> His blood pressure is still in 120s.
2459.089 -> He's on two blood pressure medications,
2462.159 -> and he's doing well.
2465.196 -> [crosstalk] So, Rob Phillips one more time.
2471.535 -> So, I know you have great surgery in Alabama.
2475.706 -> It's not impossible that he could have
2479.076 -> a late paravalvular leak - He did not.
2482.58 -> Okay.
2487.251 -> I would say that the reduction in stroke volume isn't all
2491.188 -> that relevant because before surgery,
2494.758 -> much of the stroke volume was wasted, so...
2501.866 -> it can't fully explain.
2506.203 -> Although it reminds somewhat what in the old days was
2511.242 -> called decapitation of blood pressure after myocardial
2515.145 -> infarction, and subsequent reduction of stroke volume.
2522.119 -> [crosstalk] So, just wanted to say that he was hyperdynamic
2527.157 -> before surgery, and there was normal hemodynamics
2531.695 -> after the surgery.
2532.296 -> Not uncommon clinical circumstances.
2534.164 -> The poorly treated, difficult to manage hypertensive on
2538.235 -> five-drug therapy who gradually develops systolic
2541.171 -> heart failure and the blood pressures normalize.
2543.507 -> That's what you saw here.
2544.875 -> Yeah.
2545.409 -> And the prediction would be as the EF goes up
2547.978 -> gradually over time, you're going to need Amlodipine
2550.014 -> and two or three other drugs to come in board,
2552.516 -> so it's just the hyperdynamic nature of it.
2554.952 -> But you have a clinical corollary that no doubt
2557.588 -> you see in Alabama in the same way.
2559.99 -> So, when someone comes in all of a sudden well-controlled,
2563.294 -> you get asked the question of, "What happened to their EF?"
2566.764 -> Yeah.
2567.431 -> So, [inaudible] we need to wrap up.
2569.667 -> Okay.
2571.101 -> Thank you and wrap up.
2572.169 -> Alright.
2573.437 -> Do you want to?
2574.038 -> It's okay.
2574.505 -> Well, that was really a tour de force in both of these cases.
2577.775 -> I think all of us, despite our vast experience,
2581.612 -> learned a lot from the two of you today,
2584.081 -> and hope you enjoy the rest of the meeting.

Source: https://www.youtube.com/watch?v=vmIyWz69ZiA