Thickened leaflets......questions!

[Mb]

Hello everyone!

My husband finally had the second TEE done on Friday, and after having worried for three days, the report came back with only mild mitral regurgitation, so at least that wont need to be fixed at his second OHS scheduled for 1/24. (He is to have his tricuspid valve repaired, and a permanent pacemaker installed.)

I got a copy of the report today, and e-mailed his doctor. When visiting his surgeon three weeks ago, we discussed the fact that he has rheumatic heart disease (two St. Jude valves), and was there a possibility that the tricuspid valve had rheumatic involvement as well. The surgeon replied that he would not really know that until the surgery, and if it was damaged from the rheumatic heart disease, then the valve would have to be replaced with a bovine valve. The pacemaker leads would be placed on the outside of the heart, and the device placed in his stomach. - Now the report comes back and says in addition to the valve not closing, as the annulus is stretched so wide, but the leaflets are thickened. He also has a prominent eustachian valve. Ever heard of that one???? (Left over from embryonic developement).
E-mailed his cardio, who repeated what the surgeon said, regarding repair/replacement of the valve.

Does anyone have any input about the leaflets thickening?

Marybeth

 

[tobagotwo]

Generally, the leaflets thicken when they are being coated with apatite, or when there is vegetation.

However, I am always suspicious about a revelation of thickened leaflets, as I was told a few months before my aortic surgery that my mitral leaflets were thickened. After the AVR, the supposed thickening in the mitral leaflets was nowehere to be found.

I believe, and this is just a theory, that there is a certain amount of flutter or vibration of the leaflets that occurs during opening and closing when there are issues with the bloodflow, particularly regurgitation. This may cause a sonographic shadow effect.

Plainly, I could be wrong. However, if there is no other sign of calcification or vegetation, it's a possibility to keep in your mind.

Best wishes,

 

[Mb]

Dear Bob:

Wow, you certainly know a lot! Thank you for your reply. He did have two TEE's last week, and although both showed they were thickened, I can certainly understand you comments, and hope you are correct. Since your knowledge seems fairly broad in scope, do you know if they might still do an annuloplasty on the tricuspid valve, even if the valve leaflets are thickened?

Another question.....is this apatite you spoke of.....is that from rheumatic involvement? I know my husband will be none too happy if they have to replace the valve, and insert the leads on the outside of the heart, and the device in the stomach. It has taken him 3-4 years to finally agree to having a pacemaker, as he is getting more dizzy spells and heart rate pauses. Also his ectopic beats increased rather dramatically as well.

Again, thank you for your reply. Any additional comments you might have would be very very welcome.

Marybeth

 

[tobagotwo]

A repair attempt would depend on the amount of thickening, whether there is siginificant calcification (apatite formation), and the stability/repairability of the valve root, to restore the valve's proper shape.

The mitral valve is on the left side of the heart (which pumps blood to the body). The tricuspid is on the right (which pumps to the lungs), in effectively the same functional position that the mitral takes up on its side. The mitral and tricuspid valves are like parachutes, in a way. They are held in proper place by "guy wires" of tissue, called the Chordae Tendineae, which are held by the papillary muscles, which are attached to the inner wall of the ventricles. When the blood tries to flow back against the valve leaflets, they "balloon out" and hold against the flow with the help and guidance of these tissue "guy wires." The key to the repair will be how good these components are, as well as the tissue of the ventricular inner wall that the surgeon will want to anchor those repairs to.

If he has calcification on his tricuspid valve, it would theoretically be because the body has identified it as damaged or dead tissue by the chemicals on its surface. This could well be from damage done years before by the rheumatic fever (bacterial endocarditis and various viruses can also cause this).

Apatite is the name of the actual mineral that builds up on damaged valves, which is more commonly referred to as "calcification." There is calcium in it, to be sure, but also phosphorus and a variety of other minerals. It's the same mineral (with some variation in content ratios) that makes up your bones, and in a diffferent ratio, your teeth. The composition varies from place to place in your body, and may have differences in coloration, hardness, and brittleness based on trace elements and mineral ratios.

A seagoing geologist who was aboard the VR.com site some time ago coined the phrase "cardiolytic apatite," meaning either that it's related to the heart, or that it helps to effect the heart's decomposition, either of which is a fairly apt description.

This is one of the reasons why cholesterol-related inquiries into valve calcification are likely doomed to failure. This is a bone-building process, similar to the boney encasement of foreign bodies lodged internally, rather than a process of developing structurally-enhanced fatty buildup.

Best wishes,

 

[ALCapshaw2]

Most surgeons don't like to replace the Mitral Valve until it is Severely Damaged, and many seem to think this may not occur in the near future.

That is not always the case, especially for radiation damaged hearts.

Another useful measurement is the pressure GRADIENT across the valve. A good Mitral Valve will show less than 10 mmHg (millimeters of Mercury) pressure gradient. It is sometimes useful to measure the gradient after STRESS (i.e. walking on a Treadmill until you reach 90% of your age specific Heart Rate). A significant* amount of increase in the gradient during / immediately after stress can be another indicator that it is time to replace the valve. Ask your Cardiologist what he considers a 'significant' increase to be.

'AL Capshaw'

 

[Mb]

I am not sure if I made myself clear or not.

My husband has a St. Jude mechanical valve. They have deemed the leakage to be mild to moderate. So, nothing to be done to that.

His tricuspid valve is another story. He has a severe leak. The "repair" they planned to do is to place an annuloplasty ring around it. However, the surgeon said if it had rhuematic involvement, then the valve would have to be replaced with a bovine valve. We are hoping for the ring, so that the pacemaker leads can be placed through his original tissue valve, into the right ventricle. If the valve has to be replaced with a bovine valve, then the leads will be placed on the outside, with the device implanted in his stomach.

We are hoping for a repair, vs. replacement, so this "thickened leaflet" issue has me concerned. You all have been most helpful explaining all of this. Frankly, I told the surgeon, that I suspected the rheumatic process at the valve, as he has had most of the typical "heart damage" caused by the rheumatic process. (two mechanicals, a-fib, other rythym issues).

Marybeth

 

[tobagotwo]

Mb, my response was aimed to the tricuspid valve. I have unintentionally muddied the waters by comparing it to the mitral valve, which is its functional equivalent for the other side of the heart. However, it was hard to resist doing so, as the repair criteria and processes are so similar, and many are familiar with mitral repairs. And I see (and corrected) where I inadvertently referred to calicifation of the mitral valve instead of the tricuspid vavle in one place. The tricuspid is less often discussed, as it's generally less critical than either of the valves on the left side of the heart, but especially in a weakened pumping system, it will add to the havoc: in this case, unacceptably.

You know that we are unable to guess what the surgeon will find with any degree of accuracy. The repair will likely be determined by a combination of things the surgeon finds at the site, into which we have little insight from here.

As far as the possible thickening of the tricuspid leaflets, the surgeon will determine at that time whether there is enough flexibility in them, or whether an irreversible process of calcification has already begun on them. I strongly suspect that the surgeon is leaning as much as possible toward a repair, but bears in mind that he doesn't want to have to re-enter your husband's heart later because of a misjudgement.

I assume the mitral leakage is at the edge of the valve (usually termed "perivalvular"), where it's attached, rather than in the mechanism itself. If there is damaged tissue at the attachment site, it would explain the reluctance to disturb the current St. Jude valve there.

Best wishes,

 

[Mb]

Dear Bob:

First, thank you for your knowledge, and a second thank you for clarifying your initial explanation. You are correct, it would be difficult not to compare the mitral on the left, to the tricuspid on the right side. Frankly, he is going to the same surgeon who installed the prosthetic St. Jude valves, some five years ago, and I know the surgeon will be extra careful this time, to make sure he leaves nothing behind. (I suspect he knows the tricuspid valve issue should have been addressed during the first surgery.)

Since you are so knowledgeable, I would like to share with you the results of the most recent echo, and get your input. I believe that your explanations will be not only helpful to me, but perhaps to a few others in the future. Right sided heart issues are not discussed often here, but I do know they happen to other folks. So here goes the echo report:

(Oh, and lastly, I am suspicious that the surgeon might want to address the prominent eustachian valve as well......what do you think?)

AO 39mm
LA 50mm
LVIDed 45mm
LVIDes 25mm
PWT 11mm
IVS 13mm
EF 69%

"There is marked incomplete tricuspid valve closure. There is color and spectral doppler evidence of severe tricuspid insufficincy with flow reversal in the hepatic veins. There is right atrial dilation. The superior-inferior RA dimension is 60mm. The medial-lateral right atrial dimension is 55mm.

Right ventricle is dilated 58mm. Systolic function is at the lower limits of normal

Those are the unusual comments. He also has chronic a-fib. Brady/tachy. And his ectopic beats increased from under 90 in the spring to 1350+- in November.

Again, thank you for everything.

Marybeth

 

[tobagotwo]

As you know, I'm not a medical professional. But I'll enter some thoughts...

For others, the eustation valve is actually more like a skin fold inside the right atrium that people have when they're still embryos. It directs the main flow of blood on the right side of the heart toward the right ventricle. It starts at the Vena Cava, and leads toward the tricuspid valve. During that stage of human embryo development, the right and left atria are not yet closed off, and the EV helps ensure that most of the correct (would-be deoxygenated) blood goes toward the right ventricle, which pumps it into and through the forming lungs. Although the lungs aren't gaining any external oxygen at that point, it forms the bloodflow path that the heart eventually grows around. If it's still present in the adult, it can partially divide the right atrium, and affects the bloodflow and pressures within the RA.

I think you're right about the surgeon possibly addressing the vestigial eustation valve. It may be partially causitive in the blood going backward into the hepatic veins, as it affects the flow and pressures within the atrium. The effect of a pronounced EV would be to partially deflect and thus slow the outflow from the hepatic (liver) veins, making it easier for back pressure to affect them, causing the reverse flow in them (while none is mentioned in the vena cava). It might also create a somewhat stagnant zone in the blood flow, which might be an area of concern for future clot generation. Fortunately, your husband is already on warfarin.

As is typical of inadequate pumping and the resultant backpressure, there is atrial enlargement. That also affects the fit of the tricuspid valve, as the root and opening are often enlarged with the rest of the atrium, distorting the shape of the valve and the opening it's trying to close. The left atrium is a bit larger than usual also, but that's probably left over from the issues that caused his previous, left-side surgery. It's fairly common that the atria don't return fully to their normal size.

The EF is 69%, which means that the left side of the heart is pumping harder to try to make up for some of the right side's weakness. The left ventricle has some hypertrophy (muscle growth) from this, although it may not yet be above the "normal" threshold. While it shows some resiliency from the left side, this is not really a positive thing overall, and should return to the mid-fifties after the successful surgery.

The dilation on the right side and the hypokinesis (limited movement - which is to say lackluster squeezing/pumping) may improve after that side of the heart is no longer overwhelmed, unless it's residual damage from the rheumatic fever. The use of the pacemaker, which should remove the AFib and ectopic beats, should give it a chance to recuperate. Were it not for the intended pacemaker, a MAZE procedure would have been a suggestion.

I hope this helps in some way.

Best wishes,

 

[Mb]

Bob:

Wow.....your answer is completely comprehensive, and makes me look at the issues from a different perspective. I had actually thought that the EF that high was not truly an overall positive thing, and that the left side was working harder than it should be, particularyly given the two prosthetic valves. Additionally, from the limited amount of reading I have done on the eustachian valve, I had suspected the surgeon might address that as well, particularly given the potential of blood stagnation, etc.

I've no idea where you have learned, and understood so much. I can only say, thank you. You have helped a great deal.

Marybeth