Urgency of AVR: what pressure gradients support a 'severe' diagnosis?

[Alan B]

Hello

I'm awaiting an AVR (and potentially a CAB) in Oxford UK. I'm a little confused from the advice I've been given concerning the symptoms I'm having and whether they require an urgent AVR, or whether they might be managed for a while before surgery becomes a real requirement (e.g if my symptoms come from Arterial narrowing, an AVR might be less urgent). I know that having the AVR done at the earliest opportunity is probably the right way to go, but I'd like to know how severe the AV stenosis usually is in people that have surgery?

I've been told that I have moderate/severe stenosis - but would be grateful for any views on what the typical pressure gradients and symptoms would be for a diagnosis (I have occassional tightness/palpitations and light headiness) - I'd like to check with my surgeon later this week.

Many thanks for your help

 

[ctyguy]

You didn't mention the measurements you have but I can tell you that my valve was to .9cm when I had my surgery. I think anything less than 1cm is considered severe, As far as the gradient goes, I was told that 20 is the typical number they look for. Mine was peaking at 115 which is NOT good.

With those numbers I was advised surgery as soon as possible. 15 days later to be precise !

Best of luck to you...

 

[tobagotwo]

Here are trhe generally recognized values (this is for mean - average - pressure gradient, not peak):

Mild: less than 25mmHg (valve area 2.0 cm² - 1.5 cm²)
Moderate: 25mmHg – 40 mmHg (valve area 1.5cm² - 1.0 cm²)
Severe: more than 40mmHg (valve area 1.0 cm² - 0.6cm²)

Anything beyond severe is critical - I would certainly not get below .9cm² or .8cm² in valve area at worst. Other issues with the heart start cropping up by then that can become permanent, even after the valve is fixed.

It has become fashionable in some cardiology circles to wait replacement for women until .6cm². I personally believe it's a disservice to women in general, a dangerous practice for the patient, and that it can unnecessarily risk permanent heart function damage. It also allows the patient to fall into a more weakened state for the surgery than necessary, which may affect the effects of surgery and may slow the recovery. But I'm not a cardiologist, just a concerned amateur.

I also note that the accuracy of measurements from TEE (TOE in the UK), regular echo, and even cardiac catheterization can be .1cm² -.2cm² off (meaning a .6cm² could actually be a .4cm²). I'd rather have the operation a silly millimeter early than a not-so-silly millimeter late. I want my heart fixed and working normally, not a sincere apology.

The most important factors in determining time for surgery really seem to be: valve opening size; presence and extent of regurgitation; left ventricular hypertrophy (amount and speed of the growth of the left ventricle); and general symptoms, such as angina (heart pain felt as chest, arm, back throat or jaw pain or discomfort), shortness of breath (dyspnea [might be dyspnoea in the UK]), and feeling woozy or faint (syncope).

Best wishes,

 

[Bina]

Hello Alan and welcome.
My docs followed the size of my aortic valve opening using an echo, or TEE, every year.
When I was at my worst and very incapacitated, my valve area was .8cm

 

[Woodbutcher]

hi Alan, I'm down in Cornwall and had very severe stenosis a few months ago. At a guess if you've been diagnosed with moderate/severe stenosis then your AV area will be about 1.0cm2 , severe would be under 1.0 and an operation would be requested at around 0.8. Whether or not they operate before then will be decided upon your symptums, of which you seem to be showing signs of. Otherwise the transition from moderate to severe can take a few years. In my case I went from 1.1 - 0.5cm2 in 12 months.
You've been diagnosed and being watched that's the main thing.

 

[ALCapshaw2]

You didn't mention the measurements you have but I can tell you that my valve was to .9cm when I had my surgery. I think anything less than 1cm is considered severe, As far as the gradient goes, I was told that 20 is the typical number they look for. Mine was peaking at 115 which is NOT good.

With those numbers I was advised surgery as soon as possible. 15 days later to be precise !

Best of luck to you...

Technically, "Valve Size" is expressed as "Effective Valve Area" in units of "Square cm" (or cm^2), NOT as a Linear Measurement (in cm).

Gradients represent the "Differential Pressure" across a valve, typically expressed in units of "millimeters of Mercury" (mmHg).

'AL Capshaw' (the Engineer in me made me do it)

 

[Simon Booker]

Mini AVR?

Mini AVR?

Scott - your footer says that you had a 'mini AVR'. Might you tell me what this is? I've been told (over here in the UK) that a minimally invasive option is not available/advisable for AVR, but for other valves it is a possibility.

Many thanks

 

[ctyguy]

mini-AVR = minimally invasive AVR. Instead of a full sternum chest crack (8 inch incision) my incision was 4.5 - 5 inches. Its still down the center of your chest and they still have to cut bone but I don't think they cut the entire sternum. They cut a portion and then use a rib spreader to give the opening to the surgeon. Its interesting that your being told its not an option. My surgeon said that for him that was his standard procedure for an AVR as long as there were no other mitigating factors. Beyond the bad valve I had no other issues. I also think the technique Dr P used help me heal faster. I was back at work at just over 5 weeks post-op.

 

[Mary]

My valve area was calculated at .9cm sq. and my mean pressure gradient was 55 mmHg; I was symptomatic, but it took several TIA episodes to accelerate the surgery date.

 

[Alan B]

Thanks for your responses - update

Thanks for your responses - update

Seen the consultant today - got my stats today and general update - around 1.0 valve area and pressure on the high side (up to 60 hgmm) so have been put on the list for surgery within the next 3-4 months. Got to make some choices around valve types now, but at least we are making progress. The Hospital were talking about a Carbomedics mechanical valve - or the Edwards Perimount Magna (for tissue). Anyone heard of he Carbomediics valves - much of the discussion on this site seems to focus around the St Jude or On-X mechanical valves?

Thanks again

Alan

 

[Bina]

Carbomedics is a really good one too. They are similar to St.Jude.

 

[Bina]

www.carbomedics.com