47. Case Report: Syphilitic Aortitis with Severe Aortic Regurgitation – UT Southwestern

CardioNerds (Amit & Dan) join UT Southwestern cardiology fellows (Shreya Rao, Sonia Shah, and Nick Hendren) for some delicious Dallas Tacos! They discuss a fascinating case of syphilitic aortitis with severe aortic regurgitation presenting as cardiogenic shock. Program director Dr. Gail Peterson provides the E-CPR and a message for applicants. Episode notes were developed by Johns Hopkins internal medicine resident Evelyn Song with mentorship from University of Maryland cardiology fellow Karan Desai. 

Jump to: Patient summaryCase figures & mediaCase teachingEducational videoReferencesProduction team

CardioNerds Cardiology Podcast: Episode 47: Syphilitic Aortitis with Severe Aortic Regurgitation - UT Southwestern
Episode graphic by Dr. Carine Hamo

The CardioNerds Cardiology Case Reports series shines light on the hidden curriculum of medical storytelling. We learn together while discussing fascinating cases in this fun, engaging, and educational format. Each episode ends with an “Expert CardioNerd Perspectives & Review” (E-CPR) for a nuanced teaching from a content expert. We truly believe that hearing about a patient is the singular theme that unifies everyone at every level, from the student to the professor emeritus.

We are teaming up with the ACC FIT Section to use the #CNCR episodes to showcase CV education across the country in the era of virtual recruitment. As part of the recruitment series, each episode features fellows from a given program discussing and teaching about an interesting case as well as sharing what makes their hearts flutter about their fellowship training. The case discussion is followed by both an E-CPR segment and a message from the program director.

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Patient Summary

  • A 57 year old male presents with 3 months of progressive dyspnea on exertion, orthopnea and lower extremity edema. However, his symptoms suddenly worsened over the past few days. He has no other known medical history or prior surgeries. Further, he denies tobacco, alcohol or illicit drug use and reports a preference for male sexual partners.  
  • On presentation to the hospital, he had a markedly wide pulse pressure, a decrescendo diastolic murmur at the left upper sternal border and a water hammer pulse readily identifiable. TTE confirmed the clinical findings of severe aortic regurgitation with holodiastolic flow reversal in the thoracic, as well as the thoraco-abdominal aorta. Right heart catheterization was performed and showed equalization of the LVEDP and aortic diastolic pressure at 40 mmHg with Cardiac Output of 1.73 L/min. RPR was positive at a high titer (1:512). He was ultimately diagnosed with syphilitic aortitis with severe aortic regurgitation.  
  • He progressed to cardiogenic shock and was managed with nitroprusside, dobutamine, and furosemide infusion as well as IV penicillin for syphilitic aortitis and presumed neurosyphilis. The patient was stabilized and eventually underwent an uncomplicated prosthetic aortic valve replacement and aortic root resection and reconstruction and has done well post-operatively!  
  • Pathology was consistent with syphilitic aortitis: “lymphoplasmacytic inflammation, large foci of necrosis, and neovascularization” 

Case Media


Episode Schematics & Teaching

The CardioNerds 5! – 5 major takeaways from the #CNCR case

  1. When suspecting severe AR, first characterize the AR as either acute or chronic based on clinical evaluation and hemodynamics. From there, AR can further be characterized as primary (valve disorder) or secondary (disorder of the aortic root/aorta). 
  2. Chronic AR exposes the LV to volume overload (leading to increased LVEDV), afterload, and increased wall stress. Chronic severe AR has two phases: 
    • Compensated Phase: Responding to increased wall stress, eccentric hypertrophy occurs. LVEF is maintained during this stage, though LV dilation may begin to occur. Patients are typically asymptomatic.  
    • Decompensated Phase: Eventually, compensatory mechanisms are insufficient and significant LV dilation occurs and LVEF decreases. Patients will develop exertional dyspnea and CHF symptoms.   
  3. The physical exam of patients with chronic AR is full of classic findings and eponyms! Specifically, regarding murmurs of AR, there is the classic diastolic, blowing, decrescendo murmur heard in the LUSB. Typically, the severity of AR correlates with the duration of the murmur more than the intensity. 
  1. Some 2D echo findings of chronic, severe AR include pressure half-time less than 200 ms, holo-diastolic flow reversal in the proximal descending aorta and/or abdominal aorta, and a dilated LV due to remodeling. Other criteria include vena contracta > 0.6 cm, flail valve, regurgitant volume > 60 mL/beat, regurgitant fraction > 50%, and LVESD > 50 mm.  
  2. The goal of management of acute AR is temporary stabilization before proceeding with surgical intervention. This includes vasodilators to reduce afterload and potentially inotropy to support cardiac output. Avoid excessive negative chronotropy as it can prolong diastole and worsen acute AR. If patient is bradycardiac, can increase HR with beta agonists or temporary pacing to decrease time spent in diastole.  
Produced by Dr. Karan Desai, MD

References

CardioNerds Case Reports: Recruitment Edition Series Production Team

27. COVID-19: ID Part 4: Virology and epidemiology with Drs. Chida and Nematollahi

Infectious disease experts from the Johns Hopkins Hospital, Drs. Natasha Chida and Saman Nematollahi join the CardioNerds for a 4 part COVID-19 infectious disease series. In this final episode, we discuss the virology and epidemiology of SARS-CoV-2 that serves as the underpinnings for the three prior episodes. Flutter Moment by Dr. Sumeet Bahl (Vascular and Interventional Radiology)

We are honored to promote the incredible efforts of #GetUsPPE, a nonprofit organization working hard to make sure every healthcare worker is protected. Dr. Seth Trueger, emergency medicine physician and digital media editor @JAMA Network Open shares an earnest request.

In light of the COVID-19 pandemic, we shifted gears to meet the educational need as we all are learning more about the cardiovascular implications of SARS-CoV-2. On the CardioNerds COVID-19 series page, you will find our collection of podcast episodes, infographic, youtube videos, curated #Tweetorials, references, guest experts & contributors, flutter stars and so much more.

Check out the COVID-19 series page!
Take me to episode topics page
Click here for Youtube COVID-19 Playlist
Click here for our Youtube CV fundamentals playlist

Dr. Natasha Chida, an infectious disease expert at Johns Hopkins. Dr Chida received her MD from the University of Miami Miller School of Medicine, where she also earned an MSPH (masters of science in public health). She completed internal medicine residency at Jackson Memorial Hospital and infectious disease fellowship at Johns Hopkins, where we were lucky to keep her on as faculty. She is a truly incredible educator and mentor to all levels of trainees — she serves as assistant director of the infectious disease fellowship program, co-director of the medical education pathway for residents, director of education for the Johns Hopkins Center for Global Health Education, and course director for the ‘Topics in Interdisciplinary Medicine’ course for medical students.

Dr. Saman Nematollahi grew up in Tucson, Arizona. He completed his undergrad at the University of Arizona with dual degrees in Physiology and Spanish Literature. He spent some time after undergrad working in a neuroscience lab before starting med school at the University of Arizona. He then moved to NYC where he completed residency at Columbia. His clinical interests include management of immunocompromised hosts, and his research interest is in medical education.  More than that he is a teacher at heart and is obtaining a Master’s of Education at the Johns Hopkins School of Education and was recently awarded a grant to develop a fungal diagnostic curriculum for residents. He loves to play soccer with his wife and son. He is master educator, appeared on and has authored many important tweetorials. He has also appeared on the hit medical podcast, The Clinical Problem Solvers.

24. COVID-19: ID Part 1: Emerging treatments with Drs. Chida and Nematollahi

Infectious disease experts from the Johns Hopkins Hospital, Drs. Natasha Chida and Saman Nematollahi join the CardioNerds for a 4 part COVID-19 infectious disease series. In this first part we discuss the emerging therapies in our armamentarium. Be sure to stay tuned for the remaining 3 parts in which we tackle advice for the health care worker, the clinical presentation & diagnosis, and the virology. Flutter Moment by Dr. Justin Berk (Medicine/Pediatrics).

Check out the COVID-19 series page!
Take me to episode topics page

Dr. Natasha Chida, an infectious disease expert at Johns Hopkins. Dr Chida received her MD from the University of Miami Miller School of Medicine, where she also earned an MSPH (masters of science in public health). She completed internal medicine residency at Jackson Memorial Hospital and infectious disease fellowship at Johns Hopkins, where we were lucky to keep her on as faculty. She is a truly incredible educator and mentor to all levels of trainees — she serves as assistant director of the infectious disease fellowship program, co-director of the medical education pathway for residents, director of education for the Johns Hopkins Center for Global Health Education, and course director for the ‘Topics in Interdisciplinary Medicine’ course for medical students.

Dr. Saman Nematollahi grew up in Tucson, Arizona. He completed his undergrad at the University of Arizona with dual degrees in Physiology and Spanish Literature. He spent some time after undergrad working in a neuroscience lab before starting med school at the University of Arizona. He then moved to NYC where he completed residency at Columbia. His clinical interests include management of immunocompromised hosts, and his research interest is in medical education.  More than that he is a teacher at heart and is obtaining a Master’s of Education at the Johns Hopkins School of Education and was recently awarded a grant to develop a fungal diagnostic curriculum for residents. He loves to play soccer with his wife and son. He is master educator, appeared on and has authored many important tweetorials. He has also appeared on the hit medical podcast, The Clinical Problem Solvers.