A 23-year-old man is evaluated for a murmur discovered at a health fair. His past medical history is insignificant, and he feels well with no cardiac symptoms. The patient plays soccer and jogs regularly. His immediate family is healthy. Blood pressure is 122/70 mm Hg and pulse is 72/min. A 2/6 midsystolic murmur is heard at the left sternal border. The femoral pulses are full, and there is no brachial-femoral pulse delay. Echocardiography shows bicuspid aortic valve with a mildly increased gradient and no dilation of the aortic root. Which of the following is the best next step in management of this patient?

Question

A 23-year-old man is evaluated for a murmur discovered at a health fair.  His past medical history is insignificant, and he feels well with no cardiac symptoms.  The patient plays soccer and jogs regularly.  His immediate family is healthy.  Blood pressure is 122/70 mm Hg and pulse is 72/min.  A 2/6 midsystolic murmur is heard at the left sternal border.  The femoral pulses are full, and there is no brachial-femoral pulse delay.  Echocardiography shows bicuspid aortic valve with a mildly increased gradient and no dilation of the aortic root.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_be1f_5f3f_8f63_d98433f736eb_MD0005_00 Bicuspid aortic valve (AV) is one of the most common (about 1% of the population) types of congenital heart disease. It can occur sporadically or as an autosomal dominant inherited disorder with incomplete penetrance. Patients with uncomplicated bicuspid valves typically have an ejection murmur and a sound or click best heard at the lower left sternal border. Chest x-ray is usually unremarkable but can occasionally reveal AV calcification, aortic enlargement (due to aneurysm), or rib notching (due to coarctation). Transthoracic echocardiogram is recommended for diagnosing bicuspid AV and for follow-up. First-degree relatives also should be screened for bicuspid AV to avoid complications including severe regurgitation, stenosis, ascending aorta or aortic root dilation, and dissection. Patients are at increased risk for endocarditis due to abnormal valve anatomy and function; however, routine antibiotic prophylaxis is not recommended. (Choice A) Bicuspid AV can be associated with other congenital cardiovascular anomalies including coarctation of the aorta, sinus of Valsalva or ascending aortic aneurysm, supravalvular or subvalvular stenosis, and ventricular septal defects. Coronary artery anomalies, including anomalous origin of the arteries, are also seen in some patients. However, routine screening for coronary anomalies is not recommended in patients with bicuspid AV. (Choice B) AV replacement is indicated in patients with severe aortic stenosis or regurgitation associated with symptoms of left ventricular dysfunction. (Choice C) Balloon valvuloplasty is indicated in symptomatic and asymptomatic (if they plan to become pregnant or participate in competitive sports) young adults when the following criteria are met: Aortic stenosis No significant AV calcification or aortic regurgitation Peak gradient >50 mm Hg (Choice D) Screening for renal artery stenosis using Doppler ultrasound is helpful in patients with resistant hypertension refractory to antihypertensive therapy. There is no such indication in this patient. Educational objective: Bicuspid aortic valve is an autosomal dominant trait with incomplete penetrance, although it can also occur sporadically. Current guidelines recommend echocardiography screening of first-degree relatives.

A 23-Year-Old Man Is Evaluated for a Murmur Discovered at a Health