In August last year, I had a 45 second or so episode of double vision (diplopia) while driving in the fast lane. It momentarily made driving safely extremely difficult. The double vision eventually resolved, and I hogged the slow lane back to London without a recurrence of the issue.
I thought the diplopia may have been tiredness/eye strain from driving or low blood sugar. But I erred on the side of caution and got it checked out.
At the A&E they did a thorough work up… full blood count, MRI head scan, carotid artery echo, bloods for endocarditis. All came back clear. Was referred to ophthalmology for eye tests. Those tests all proved clear.
In early December, I was out and about and suddenly felt unwell and lightheaded and headed for home. Once home, I still felt queasy and dizzy, but then suddenly my left arm and hand felt a tad heavy and disconnected.
I’m having a stroke, I thought.
I sat myself down considering what to do, and things appeared to resolve themselves just as quickly as they had begun. I headed for A&E.
Had a variety of tests at A&E and initially treated as trans ischaemic attack and loaded with Aspirin 300 mg to be taken daily (up from my usual 75mg daily) and discharged with TIA clinic follow-up.
An MRI of my head a few days later showed tiny cerebellar infarcts, which the consultant said might explain my symptoms. It thankfully wasn’t a bigger and more debilitating cerebellar infarction. These tiny infarcts were new and not showing on my previous August MRI following the double vision episode. I’ve noticed distinct short-term memory issues since this “minor stroke”.
The stroke consultant wanted to rule out cardio-embolic source of the ischaemic stroke, considering my background history of bioprosthetic valve.
Told to stop aspirin and switch to Clopidogel 75mg daily until further notice. There was to be no driving for one month.
New blood cultures for endocarditis came back negative. Full bloods taken all looked fine. Wore an ECG monitor for 7 days. Lots of stuff in that, but I wasn’t sure how to read it. They were mainly testing for atrial fibrillation, which didn’t seem to be an issue. There was another clear scan of the carotid artery.
A recent related (29 February) echocardiogram result came back, and it states:
On comparison to previous echo April 2023 at GSST, there is an increase in gradients across the aortic valve replacement.
Tissue aortic valve in situ appears well seated.
Peak v max 3.8 m/s,
gradient 58 mmHg,
mean 28 mmHg,
functional AVA 1.1cm²
DVI 0.31.
No obvious regurgitation.
Dilated LA (Left Atrium).
This shows my gradients are up from April 2023 and considerably up from a 4 month post August 2019 replacement reading of peak gradient 22mmHg and mean gradient 12mmHg.
For context, my final gradients pre AVR op were mean 60mmHg, peak 33mmHg
My aortic valve area is now moderate at 1.1cm². 4 month post replacement aortic valve area was 1.8cm². So edging towards severe.
Left Atrium dilated. Not sure of the significance of that.
I had an annual cardiac review booked for late May but had an urgent cardiology consultation a few days ago.
The cardiologist did a review and now wants me on warfarin, probably indefinitely, because of the cerebellar infarcts. She also suggested a low dose beta blocker (Bisoprolol) for the higher ventricular ectopic beats percentage that she noted reviewing the 7 day Holter monitor data.
She’s arranging an urgent cardiac angio CT scan of my 4 ½ year-old Inspiris Resilia bioprosthetic valve to look for any issues (BPVT – bioprosthetic valve thrombosis being one of them, I believe). The cardiologist confirmed my aortic valve area is now moderate and will monitor it again in six months with an echo. She will liaise with the stroke clinic.
She said my readings were not suggesting another surgery at this stage. But let’s see where things are in a year or two and what happens to my gradients and aortic valve area with warfarin treatment. Perhaps they will stabilise? Or better, I’m hoping the warfarin will reduce the current gradients. I read something about the possibility of that effect in a number of research papers. Let’s see.
Valve in valve (TAVI/TAVR) does not appeal to me for various reasons and is an unlikely option anyway I imagine, considering I have first degree heart block and left bundle branch block from my previous AVR surgery, plus the infarcts.
Should the day for re-operation arrive anytime in the next few years, I’m currently inclined to go mechanical. At least I will be warfarin savvy and well practiced by then… he said hopefully!
Onwards.
