1. Acute heart failure and significant aortic valve stenosis Prof. Dr. W. Van Mieghem 13-09-2008

2. A.F. 75 year old male patient Antracosilicosis Arterial hypertension Type II diabetes mellitus Cigarette smoker Peripheral vascular disease with bypass surgery right femoral artery and amputation first toe left foot

3. A.F. Coronary artery disease Myocardial infarction 11/2002 CABG: critical main stem stenosis stenosis RCA 12/2002 Degenerative aortic stenosis Heart failure 5/2003 New onset angina pectoris 12/2007

4. Acute HF hospitalization 13/08/2008 Raised jugular venous pressure Pulmonary oedema Aortic valve stenosis

8. Coronary arteriography LIMA -> LAD: normal function RIMA -> RCA: normal function SVG -> CX: normal function

12. Pulmonary function FVC 1,43 l= 40% normal value FEV 1 1,41 l= 60% normal value R.V. 0,96 l= 38% normal value TLC 2,3 l= 41% normal value

13. Duplex carotid arteries 90% stenosis RCA

15. How to treat this patient?

16. Cardiac MRI The myocardium is thinned at the apical level with a diffuse delayed enhancement and moderately dyskinetic movement during the ventricular contraction Fibrotic and non-viable tissue

19. Proposed treatment Right carotid endarterectomie Aortic valve replacement Aneurysmectomie

20. Operation: Succesfull right carotid endarterectomie Extremely difficult dissection because of extensive pericardiac fibrosis with massive adhesions Aortic valve replacement with bioprothesis Aneurysmectomie not performed because of technical difficulties The postoperative cause was complicated with a right sided pneumonia and the patient remained on the respirator for 30 days Patient is still mentally recovering