A 55-year-old man with a history of erosive, seropositive
rheumatoid arthritis (RA), and
interstitial lung disease presented with
shortness of breath. Echocardiography showed new-onset severe left ventricular (
LV) dysfunction with an ejection fraction (EF) of 15% and moderately increased mean aortic valve gradient of 20 mmHg in a trileaflet aortic valve with severe sclero-calcific degeneration. Coronary angiography revealed no significant obstructive
coronary disease. Invasive hemodynamic studies and
dobutamine stress echocardiography were consistent with moderate
aortic stenosis. Guideline directed medical
therapy for
heart failure with reduced EF was initiated; however,
diuretics and neurohormonal blockade (beta-blocker and
angiotensin receptor blocker) provided minimal improvement, and the patient remained functionally limited. Of interest, echocardiography performed 1 year prior to his presentation showed normal LV EF and mild aortic leaflet calcification with moderate
stenosis, suggesting a rapid progressing of calcific
aortic valve disease. Subsequently, the patient underwent surgical aortic valve replacement and demonstrated excellent postsurgical recovery of LV EF (55%). Calcific
aortic valve disease is commonly associated with aging,
bicuspid aortic valve, and
chronic kidney disease. Pathophysiological mechanism for valvular calcification is incompletely understood but include osteogenic transformation of valvular interstitial cells mediated by local and systemic inflammatory processes. Several rheumatologic diseases including RA are associated with premature
atherosclerosis and arterial calcification, and we speculated a similar role of RA accelerating calcific
aortic valve disease. We present a case of accelerated aortic valve calcification with (only) moderate
stenosis, complicated by a rapid decline in LV systolic performance. Guidelines for AVR in moderate
stenosis without concomitant cardiac surgery are not well established, although it should be considered in selected patients.