Differing cardiologist recommendations

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Nelle

Hello All

I'm fairly new to this site and recently posted that I would possibly be having surgery in January. In 2003, when my primary cardiologist first told me I would need valve replacement, I went for opinions from other cardiologists. Other cardiologists said that I would need a replacement but not yet. Today I saw one of the "other" cardiologists who told me after seeing my stress echo results from last week, that he thought I should not have surgery now. He said I should wait as long as possible before doing this surgery and based on test results, it looks like now is still not the time.

He gave me the name and number for another cardiologist that he respects and who is not affiliated with a surgeon, has no reason to send me to surgery. I will do as he suggests.

My primary cardiologist says I should get the replacement now. He thinks I should have had it done already.

Has anyone had an experience where cardiologists make such varying recommendations? Do any of you think that had you seen a different cardiologist, that the decision for surgery would be different?

Not sure what to do.
Nelle
 
Nelle, I think these decisions can be based on 2 things:
Firstly, how do you feel....only you know this..... how bad or good do you really feel.
Secondly, test results.....they don't lie, and can show problems which you may not have symptoms for yet.
Cardiac issues and choices are not to be taken lightly, I hope you find some answers soon.
 
This certainly is the risk when getting second opinions. The questions you need to ask yourself is which opinion you feel the most comfortable (and possibly get another one). The Cardio that wants you to move forward with surgery - why does he want you to move forward? Is your heart enlarging? Is there are risk of permanent damage? Are you experiencing symptoms? The one that says you should wait - Does he feel your condition is steady? You should move forward with whatever explanation you are the most comfortable with.

Most of the people on this site will typically say that you should just get it done. It's just not worth risking permanent damage to your heart when it is avoidable. I've never seen a single person on this site post-op that has said that they wish they waited longer. I have, however, seen several people say that they wish they had done it sooner. The decision, however, is of course very personal and one that you need to make on your own.
 
Mike did a very good explanation of the typical thought process. You've left out a lot of information as to what you are experiencing, what your tests are showing (are they showing a progression or have they not changed?)

We often say here that cardiologists tend to be conservative on when to operate, so one saying he wants you to wait isn't surprising and makes me want to know why the one that thinks you should have had it done by now has those thoughts. Most surgeons will not tell you to have the surgery if you truly don't need the surgery. I had a surgeon tell me I wasn't ready yet. So don't think that just by getting a surgeons opinion means that they will say you need the surgery. We also often say that many cardiologists want to wait until they see evidence of damage, while surgeons want to operate before permanent damage is done. Truthfully, you are much ahead of the game if you go into surgery without evidence of permanent damage.

But you need to know specifics. Get copies of all your tests since 2003 and start seeing what changes have occurred. We have many members here who can help you out with measurement numbers and terminology.
 
Five years ago my cardiologist drops my health insurance, of coarse that was when I started having all the signs (chest pain, bowling ball on chest, fatigued) that it was time for surgery. I went to a cardiologist that always makes the top list in the magazine for Atlanta. I don?t think he even looked at my past health history chart or echo because he had me going to a surgeon. I went to another cardiologist for a 2nd opinion and was told that we needed to get my blood pressure under control. Bingo my chest pains and fatigued stopped with blood pressure medicine. I have been seeing this cardiologist for five year now. A few weeks ago my yearly echo was saying that it was time for surgery and my cardiologist refer me another doctor and that doctor had me repeat with the longest echo (2D&3D, bubble test) I have ever had at a heart hospital. The test results of the echoes were different and I am still in the waiting room. In six months I will have another echo at my cardiologist office. If I were you I would go for the 3rd opinion and maybe see if they can repeat the test.

God Bless!

Rebecca
 
I'm a believer in multiple opinions. I've learned new and useful things about hearts in general and my heart in particular from every Cardiologist and Surgeon I've interviewed.

OLD Schoold Cardiologists tended to take the "wait and see" approach, often waiting until symptoms were seen (indicating that DAMAGE was being done to the heart).

Now that OHS has developed into a finely crafted Art-Form with incredibly GOOD results (1% risk of mortality and 1% risk of stroke) for First Time patients under age 60, most surgeons and many cardiologists are coming to the conclusion that it is best to proceed with surgery BEFORE permanent damage is done to the heart muscles and walls.

Do you have copies of ALL of your EchoCardiograms and other tests? I put my Echo Results on a Spread Sheet for easy comparison to show TRENDS, something that is NOT seen by merely looking at ONLY the Latest Echo (which some Cardiologists seem to think is all they need to know).

End of Sermon.

BTW, did you receive the e-mail message I sent through VR.com?

'AL Capshaw'
 
Usually, it is the Surgeon who makes the final judgement on whether surgery is necessary, so you may want to seek a Surgeon's opinion instead of another Cardio. In my case, my Cardio's opinion was that I needed surgery and referred me to a Surgeon. However, the Surgeon's recommendation was to wait and monitor every six months as he said it wasn't necessary yet. 18 months later I ultimately did have the surgery as the 6 month monitoring showed the problem was progressing. My mitral valve was able to be repaired and I avoided permanent heart damage. Good luck.
 
I went through the same type of thing with various opinions from various cardiologists. It made me totally crazy! If I had known as much then as I do now, I think I would have realized that it was time to have the operation. In any case, I agree with a lot of the others that say to get copies of your past echo results.
 
We have also been through the same thing but my son is a child and i know they are trying to hold out, so they can use a adult size valve. It can get very confusing when you get told you need surgery then dont:( . I dont really have any advice for you but just wanted to wish you the best of luck and hope you can get this sorted out, for something that best suits you and your situation. Good luck
 
Hello All

I appreciate all of your responses- you certainly have been there. My symptoms are progressing so slowly that it's now hard to remember what I
Should feel like. The cardio I saw yesterday is wondering what else can be giving me symptoms of hard pounding heart upon low level exercise with some sob and I feel a lot of anxiety which maybe resemble heart symptoms?? He said my heart hasn't changed since I last saw him three and a half years ago:
Left atrial dimension was 4.4, left vent. ejection fraction 75.
Echo on Oct. 1 07 shows left atrial dimension is 4.0, resting ejection fraction 65 and after exercise 80.

My primary cardio thinks I should get the replacement because my heart is in good condition now and he wants to keep it that way. His tests show a moderately dilated left atrium, ejection fraction estimated 55-60 every six months since April 06. Still gathering records prior to April 06.

In the past few years I've seen four surgeons, two said do it and two said to wait.

Rheumatic valves tend to develop permanent atrial fibrillation. Does anyone know the signs that afib is nearing?
What other damage can develop?

I'll make an appt with the other doctor that was suggested and inquire about the 3D bubble type echo. Thank you again for your help.
Nelle
 
Nelle said:
wait.

Rheumatic valves tend to develop permanent atrial fibrillation. Does anyone know the signs that afib is nearing?
What other damage can develop?
Nelle
Click to expand...

I have not had a-fib since I had it ablated during my AVR but had it several times pre-surgery. At first I was going to say that there were no signs but there were. Sometimes I would feel a "skipped" beat or a "flutter", then into full blown a-fib. And other times I just went into it with no warning.
 
Nelle said:
In the past few years I've seen four surgeons, two said do it and two said to wait.
Click to expand...

Wow, talk about being "borderline". :confused: For those recommending you wait, do you know if their opinion is surgery is inevitable but just not now, or that surgery may be avoided altogether? If it's inevitable, then personally I'd be leaning towards towards sooner, rather than later, while you are in otherwise good health and also to mitigate the risk of permanent damage. However, if there's hope OHS could be avoided altogether, then personally I'd lean towards waiting as I wouldn't want to go through OHS if I didn't have to. Sorry you are in this dilema. I hope your path becomes clear soon. Good luck whatever you decide.
 
High Ejection Fractions (above 75) can sometimes be a clue that the Heart is compensating for a narrowed valve.

One of the main things to watch for is ENLARGEMENT which can be detected by Echocardiogram (or grossly by X-Ray). At some point of enlargement, the heart will NOT return to it's normal size and that is the Permanent Damage Surgeons worry about.

'AL Capshaw'
 
Hi, Nelle...

Your quandry is a "WHEN" issue and not an "IF" issue. By that I meant that all indications are that you will need surgery and you're looking for the right time.

That being the case perhaps it would be helpful to see your heart like the engine in your automobile. If it's acting up how long do you wait before you take it in for repair? Do you get it attended to as soon as possible or wait for it to threaten a breakdown on the freeway? I can understand the "fear" factor regarding OHS but you probably already accept the necessity of having this done.

Since the onset of Afib can be subtle, and therefore dangerous, I wouldn't wait for signs of that to manifest given that the surgery is necessary anyway.

Having accepted the inevitability of the surgery I'd do it as soon as convenient and not when others tell me it's time.

Jerry
 
What I chose

What I chose

Nelle, I was told by one cardiologist I needed surgery in a matter of weeks. When I went for a second opinion, that cardiologist said to quit my job, take more meds, and wait. I had an aneurysm, and didn't feel comfortable with that threat, my heart had also nearly doubled in size. I didn't wait, and am glad I didn't. Best of luck to you. Brian
 
Hello All

I see from your responses that often times people get differing opinions on whether or not to have surgery. I must admit I am surprised to see that. I thought something this big would be less of a doctor's opinion and more of a "look at the test and see what to do" decision. Doctors are even getting different test results, one says atrium moderatley dilated, one says normal and steady.

Does anyone know what I should be looking for on a stress test result as far as left atrium size and ejection fraction?

You have all been very helpful, I do appreciate your support.

Nelle
 
Nelle,

I liked Jerry's response, especially the comment about WHEN and not IF.

Given that you will need either a Mitral Valve Repair or Replacement at some time in the future, my recommendation at this point would be to find a SURGEON with lots of Experiece and a Good Track Record for doing Mitral Valve Repairs. Once you find a surgeon you are comfortable with, then let him recommend WHEN to proceed.

My belief / hope is that a Good Surgeon won't rush you into surgery, but will recommend surgery in time to avoid permanent damage and maximize your surgical benefit.

The Key is to find a surgeon skilled in the procedure you need. Note that not all surgeons who do valve replacements are skilled at doing Valve Repairs.

'AL Capshaw'
 
I didn't see in your posts that any of the physicians you consulted said not to have surgery. They do have differing opinions as to the when. Considering that the leading cause of death among women in the US is heart disease I feel that they can all afford to error on the side of the angels.

As for EF: Ejection Fraction is a subjective measure. Each cardiologist uses his own experience to arrive at a best guess using the dopler test. If you were to take the images of the echo to several cardiologists (without the interpretations from the previous specialist) you'd receive different interpretations. I've been told that the validity of the reading increases on multiple echos done and interpreted by the same person.

In my opinion the normal size of the chambers of the heart is to some extent specific to the individual. There are "norms" that are arrived at over time and sample size. Keep in mind that Einstein's brain, if looked at by an MRI during his lifetime would have been "large" to some and "swollen" to others. "Enlarged" and "Swollen" are relative terms when compared to the sample. The most validity one can hope for is when we can compare our measurements against what they were before the condition was manifest. Again, we have to consider a comparison against the "norm" as being as valid as we can hope for. It's not the best of situations but for now it's as good as it gets.

Just my thoughts on the state of cardiology in 2006. In a few years our current state of medicine will appear as quaint and naive.
 
Nelle,

This is just my opinion, but if/when my heart began to interfear with my lifestyle, then it's time to have something done, regardless of what the cardiologists say. Secondly, my theory is "do it while you are relatively healthy". That way, your body is strong and your recovery will likely be easier and faster. I had my surgery before any blatent symptoms appeared and had one of the easiest recoveries I've heard of.

Other advice is go with a cardiologist that you like and trust. Don't be afraid to ask him for the name of a surgeon who's opinion you should get as well.
If your gut feelings are telling you something with your heart has changed, INSIST on seeing a surgeron or another cardiologist or more frequent monitoring! This saved me from probable permanent damage as my condition worsend much faster than the cardiologist anticipated.
 
Interesting I had rhuematic fever as a child and also needed a mitral valve repair/ replacement. I like what Mike had to say. I had a similar situation where my first cardiologist told me that I would need a replacement some time in the next 1 to 10 years, and he told me he would not reccomend an operation until my health started to deteriorate. Not liking the sound of that I found another cardiologist who examined me and told me I needed surgery in the next 8 months. I then was forwarded to a surgeon who had statistics that showed that for someone of my age recieiving a repair or replacement would increase my lifespan and health rather then waiting for my heart to weaken. I felt (in my heart) this was the right thing to do. Perhaps you need another meeting with your surgeon or cardiologist to clear this up. Good luck, and keep us all posted as to your decision.
John
 
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