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Question:

In this case, we will examine an 85-year-old man who is one year removed from transcatheter aortic valve replacement.  He is an 85-year-old frail-appearing man who, one year ago, underwent transcatheter aortic valve replacement with a SAPIEN 3 26 mm valve via the transfemoral approach under conscious sedation. His past medical history is notable for diabetes, hypertension, pulmonary embolism, stroke, and a history of four-vessel coronary artery bypass grafting. His medications include aspirin, atorvastatin, clopidogrel, insulin, and metoprolol. He sees you today for his routine annual exam. He reports feeling great. His physical exam is unremarkable. His transthoracic echo, however, shows increased thickness of the valve leaflets and an increase in the meangradient across the valve by 20 mm Hg compared with his baseline transthoracic echocardiogram. The transthoracic echo, however, shows increased thickness of the valve leaflets and an increase in the mean gradient across the valve by 20 mm Hg compared with his baseline transthoracic echocardiogram.

What is the next best step for the management of this patient?

  1. Initiate warfarin
  2. Repeat the transthoracic echocardiogram in 3 months
  3. Order a transesophageal echocardiogram
  4. Order a 4D volume-rendered CT scan

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