Ejection Fraction (EF) Post Surgery?

[RonP]

Hello Everyone

I’ve been lurking and reading this forum since August when I was told that I finally needed to have my mitral valve repaired. It’s been a fantastic source of information and support! Many thanks to everyone who contributes!

I had my surgery (extensive mitral valve repair, maze procedure, and left atrial appendage closure) done robotically on September 30th and I’m coming up on my 5th week anniversary on Wednesday. The surgery was long (4 hours on by-pass and 6.5 hours total) but I was out of the hospital on day #3 and was walking for 60 minutes on day #7. My incisions have healed nicely and, though I don’t think I could break into a sprint, I feel and am acting pretty normal.

However…my cardiologist had me do an echo at week #3. When I went to talk to him to hear the results he said “I have good news and bad news. The good news is that your valve is fixed and your heart has already greatly reduced in size. The bad news is that your heart is not pumping like it should. Your ejection fraction is only 25%.” Needless to say, I was shocked because I felt fine. I had no clue that anything was wrong. The next day (last Thursday) I was in for another angiogram to rule out artery damage from the surgery and get a more accurate EF measurement. There was no damage but my EF was still just at 28%. The only theory offered by my cardiologist is that being on bypass for 4 hours (actually I was on, off, on, then off again because of the complexity of the surgery) possibly damaged my heart. I’m to schedule another echo in December, 8-10 weeks post op.

My EF presurgery was in the mid 50% range.
I’m on carvedilol (6.25mg 2x) and lisinopril (2.5mg 1x).
My blood pressure is 120s/70s. My pulse is high 80’s/low 90’s (higher than presurgery).

The questions I have are:

1. Is it too soon to be concerned over the results of an echo at 3 weeks and an angiogram at 4 weeks? Would 3-6 months out be a better indicator?
2. Is it normal for the EF to be low postop? Can/does it then increase over time as the heart remodels?
3. Should I be worried about having such a low EF? Short term? Long term?
4. My doctor has not asked me to start increasing my carvedilol but everything I’ve read says that I should be stepping it up towards 25mg 2x to help my heart remodel properly. True?

Thanks!
Ron

 

[ALCapshaw2]

It sounds like it would be wise for you to have a converstion with your Surgeon about your reduced EF and prognosis. He needs to be aware of this development and hopefully he can shed some more light on the subject.

YES, I recall reading that some patients have benefited from improved EF with time. I'm thinking that MOST do NOT experience a significant drop in EF. Was your heart enlarged before surgery? Perhaps part of this issue is due to having to 'remodel' after surgery. Hopefully you will be one of the lucky ones who sees improvement over time.

The fact that you are feeling Good and Exercising without difficulty is very encouraging. Could Both the Echo and Cath been Low? Your exercise tolerance suggests that your heart is functioning better than I would expect for an EF of 25%.

Talk with your surgeon. This is definitely worth a second opinion.

'AL Capshaw'

 

[Lynlw]

What was your EF before surgery?

ps I'm curious, did they plan on you being on Bypass THAT long or did he run into problems?

 

[RonP]

I just added to the original post that my presurgery EF was in the mid 50's.

What the surgeon said about the long bypass was that he did the maze procedure, appendage closure, and valve reconstruction. They took me off bypass, did an echo (TEE), and he wasn't happy with the results. He then went back in and added and reinforced a couple of the cords and replaced the annuloplasy ring with a smaller one. He said that he did not like me being on bypass for that long and that two hours is usually his max comfort level but I needed the repairs. The possible complications he mentioned were blood clots and stroke but since that didn't happen in the OR or during my hospital stay I thought I was clear. But, now this.

Ron

 

[bvdr]

I think the left appendage closure can take quite a bit of time. I had it as part of my surgery as well. I didn't have the maze done but even so the surgery was about 7 1/2 hours and on the bypass for almost 5. I would hope for you that as your heart reduces in size, heals, and adjusts that your EF should increase. Do you know what your cardiac output (C.O.) is? I think it is great that you are feeling well even with a low EF. It seems to be adequate for your needs now and will probably improve with time. I think my first post-op echo was at my 6 months check-up and then yearly after that.

 

[tobagotwo]

I don't recall a particularly low EF post-op. I would want to contact the surgeon, to see if he can shed any light on it.

While there is no good reason provided why your EF has become so low, neither is there any good reason at this point why it can't recover, either. You're feeling generally good, and you're able to exercise (walk), This is a good thing. That doesn't mean overdo the walking and exercise. It just means that keeping with it may well help a lot.

I would consider asking your cardiologist to move you to an ACE inhibitor, instead of the Carvedilol for your BP. Beta blockers have a side effect (usually good for after surgery) of softening the beat of the heart. You really don't need any extra help with softening your heartbeat. While beta blockers like Cardevilol also slow your heart rate some (and yours is fairly fast), the EF seems more important overall to me. And having the heartbeat be more effective may allow the heart rate to go lower naturally, as it will provide the bloodflow needed to keep your body oxygenated. Just a thought.

Best wishes,

 

[Jkm7]

I would consider asking your cardiologist to move you to an ACE inhibitor, instead of the Carvedilol for your BP. Beta blockers have a side effect (usually good for after surgery) of softening the beat of the heart. You really don't need any extra help with softening your heartbeat. While beta blockers like Cardevilol also slow your heart rate some (and yours is fairly fast), the EF seems more important overall to me. And having the heartbeat be more effective may allow the heart rate to go lower naturally, as it will provide the bloodflow needed to keep your body oxygenated. Just a thought.

Best wishes,

This is what OP said he is taking:

I’m on carvedilol (6.25mg 2x) and lisinopril 2.5mg 1x.

Isn't Lisinopril an Ace Inhibitor? I believe it is angiotensin converting enzyme (ACE) inhibitor class. OP does seem to be on a low dose.
One needs to be careful about increased potassium with that drug.

 

[Debster]

Hey Ron! This was my mom totally. After her surgery-which was long long long, and she waited too long to have it done also-her EF was 20-25%. Now-4.5 years later-her Ef was 54% at last check. She is on meds like Coreg, diovan, digoxin..also has a bivent pacemaker. I believe this combo is what caused her improvement-dr said her heart has shrunk too. Woohoo!
Really-I am sure you will improve big time too. I bet the right drug combo will help tremendously, and the fact you can exercise is such a huge plus. The drs did slowly step up her Coreg to the 25mg x2 a day......Keep us posted Deb

 

[mmarshall]

Hey Ron,
I'm not sure why your cardio would tell you something like that since I would think that he/she should be more informed. I had an EF of 25% before my surgery and it took about a year for it to get back to 60%. The cardio should know that it takes time for the heart to recovery and rebuild. Now, it is possible that the heart does not fully heal and get back to normal...it's like a muscle that may or may not be able to completely heal. I could understand if your cardio told you that he/she can not make any promisses about your heart getting back to normal or the EF getting better but I do not understand why he/she would say that the bad news is that it is only 28% weeks after surgery. It's been awhile since I had surgery but I believe my EF was only at 30% 6 to 8 weeks after surgery. If you do not feel any side affects, I would follow the EF for the next 12 months and see if it improves.

 

[realkarl]

One year before my surgery when I was diagnosed, my EF was low 20s, and the heart very enlarged. After being on Carvedilol 25mg x 2 + Lisinopril 10mg x 2, Digoxin, and Spironolactone for a while it shrunk about 1/2-way to normal and I went to EF in the 40s. Before my surgery, it had started to enlarge again.

At my previous echo, about a month after surgery, the heart and specifically the left ventricle had shrunk back to almost normal, but EF still 40s. My resting HR has constantly been higher than pre-surgery at 90-100. I am on 12.5mg x 2 Carvedilol and 5mg x 2 Lisinopril + Digoxin and Spironolactone.

I was surprised the EF had not improved, but my cardiologist said the size was more important. I hope EF will improve with time and exercise. We shall see when I learn the results of yesterday's echo.

As my heart has been getting stronger, I have been increasing Carvedilol. Right after surgery, 3.125mg had the same effect as 25mg had before, but now I can take 25mg on occasion without feeling too weak after. Hopefully I can soon stop one or more of these medications gradually.

I was on bypass for 2 hours, 4.5 hours surgery time. I have been a little disappointed in how long it takes to recover, but more and more I realize, in particular from reading this forum, that it can take the heart a long time to recover, from the surgical operations themselves, time on bypass, and its bad working conditions pre-surgery.

Best wishes for a slow and steady recovery, well as speedy as possible, but we need to be patient.

 

[RonP]

Thanks, everyone, for the positive and hopeful feedback. I have an appt with the cardio's PA tomorrow and just sent in a list of questions that I want to discuss. I'm also trying to get back in with my surgeon (he's 5 hours away) to see what he thinks.

Because my surgery was out-of-town I had a temporary cardio (in addition to my surgeon) while I was in the hospital. He told me that I would probably get an echo done three months postop, then at six months, then every year after that. I was surprised when my cardio wanted one at 3 weeks. I figured that was too soon to get any reliable data but that's his protocol. He wants the next one in early December (10 weeks postop) to see if there's a trend.

Note that presurgery my EF was in the 50% range. Three-four weeks postsurgery it's 25-28%. That's why my cardio is concerned. He talked like that isn't something he normally sees.

When I was in for my angio last week (to rule out low EF caused by blockage due to incidental surgical damage) all the cardio floor nurses were saying "It's too soon to be concerned over a low EF" or "Give it some time. Your heart needs to heal." My wife said sometimes nurses know more than doctors...in this case, I hope that's true.

 

[mmarshall]

That makes sense then. I did not see the 50% then drop to 25%. I have been taking Coreg, or the generic of it, and lisinopril since surgery. They basically go hand in hand...when you're taking a beta, most cardios like to have you on an ace as well. It has done wonders for me and I was put on that to help my heart get back to it's normal size and EF...which it has done. But since it is working/worked, I don't see myself being taken off of it.
Hopefully your EF will get back to normal and your recovery will be a good one.

 

[realkarl]

But since it is working/worked, I don't see myself being taken off of it.

I was curious - if your heart has been repaired and then recovered to normal functionality and capacity, why does your cardio continue to keep you on these medications (beta-blocker + ace inhibitor)?

One of the main reasons I chose to have surgery sooner rather than later, was so that I eventually could get off these, and re-gain my past exercise capacity. At least for me, the Carvedilol reduces my max heart rate and capacity for aerobic activity rather significantly.

Which brings up one of RonP's first questions:

My doctor has not asked me to start increasing my carvedilol but everything I’ve read says that I should be stepping it up towards 25mg 2x to help my heart remodel properly. True?

My cardiologist has not mentioned this to me either, but I will ask the next time I see him. Is it best to take as much as you can tolerate (up to 25mg x 2), but how do they determine when it is OK to stop? I increased the dose from 6.25 to 12.5 to keep my heart rate in the same range, but I could increase to 25 without any problems, except reduced exercise capacity.

 

[mmarshall]

I was curious - if your heart has been repaired and then recovered to normal functionality and capacity, why does your cardio continue to keep you on these medications (beta-blocker + ace inhibitor)?

One of the main reasons I chose to have surgery sooner rather than later, was so that I eventually could get off these, and re-gain my past exercise capacity. At least for me, the Carvedilol reduces my max heart rate and capacity for aerobic activity rather significantly.

Which brings up one of RonP's first questions:

My cardiologist has not mentioned this to me either, but I will ask the next time I see him. Is it best to take as much as you can tolerate (up to 25mg x 2), but how do they determine when it is OK to stop? I increased the dose from 6.25 to 12.5 to keep my heart rate in the same range, but I could increase to 25 without any problems, except reduced exercise capacity.

I did research when my cardio put me on Coreg/Carvedilol which was about 4.5 years ago so I do not remember the specifics on all of the benefits. I do remember that it not only lowers your BP, but it helps with the blood flow, heart wall repair, etc. I was gradually moved up to 25mg and at first we were not sure if I was going to be able to. My BP did not change when I was put on lisinopril but it had a major change after Coreg. I did get to 90/60 when I first went to 25mg but it is has been stead now at 100/65. I did have a couple of times when it was 85/58 but I did not feel light headed or anything so we stuck with it.

I am happy with the results of what the meds have done for me and I have not had any major side affects so I have not pushed to be taken off. It is my personal theroy that with the low BP and benefits of the meds, that maybe I can get some extra years out of my tissue vavle since it does appear to have slowed my metabolism.

On a side note, it is also my personal belief that once a doctor puts you on meds like this, they do not like to take you off of them. Which I have no problem with my meds since it has helped me. If it works, why change. But I would have a different outlook on this if I had major side affects or affected my way of life.

 

[RonP]

I was curious - if your heart has been repaired and then recovered to normal functionality and capacity, why does your cardio continue to keep you on these medications (beta-blocker + ace inhibitor)?

I found this in the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease.

http://circ.ahajournals.org/cgi/reprint/114/5/e84

"Patients with postoperative LV systolic dysfunction, even if asymptomatic, should receive standard medical therapy for systolic heart failure, and this therapy should be continued indefinitely even if there is improvement in systolic function and/or symptoms."

Ron

 

[realkarl]

That is an interesting document. Thanks! In the same section, it also says below your quote:

LV dysfunction and clinical heart failure after valve replacement may be the result of
• preoperative LV dysfunction that persists or improves only partially
• perioperative myocardial damage
• other valve disease that has progressed
• complications of prosthetic heart valves
• associated heart disease such as CAD and systemic hypertension.

So, it appears, after a successful valve replacement, with none of the conditions listed above, and recovery goes well, one can reasonably hope for a fully restored LV function, as measured with an echocardiogram, not by symptoms, and no need for other medications than warfarin and/or aspirin. If there is any doubt at all about the LV functionality, doctors probably prefer to be cautious and continue medication.

 

[Alex B]

My EF dropped from 65% to 50% after surgery (6 weeks post op), but the cardiologist told me that he expected it would drop considerably. He told me that for me this is fine, and I should not be concerned. He also told me that everyone is different where EF is concerned. My next Echo is 6 months out.

 

[RonP]

I had a long discussion with my cardio and his PA. I also got my records from my echo and angio so I now know all the "numbers". Bottom line is that they’re not worried. He sees some patients lose EF after valve surgery but not very often does he see the steep drop that I had (60% to 28%). Most of his patients get back their EF with medication and, if necessary, a bi-ventricle pacemaker. He's hopeful that mine will come back, too.

He ruled out incidental surgical damage with the angio so he’s left with two theories. One, my heart was “stunned” by the surgery and/or the length of time (4 hours) that I was on bypass. Since that’s an electrical and/or chemical problem, it’s possible that the EF might come back as my heart heals. Two, is that the EF measurements presurgery may have been misleading because of the severely leaking mitral valve. EF is based on the ventricular volume when full and when “empty”. It doesn’t consider where the blood goes when the ventricle empties out. With a severely leaking valve, some of the blood takes the low resistance route out the valve rather than the high resistance route out into the body. My heart could have been compressing weakly but was able to achieve 60% EF because the blood was exiting out two paths. Now that the valve no longer leaks, my heart has to pump all the blood out into my body. The same amount of compression therefore nets less blood being pumped out and thus a lower measured EF. Although the net result is that my heart is weak and we don’t know why, my body may be operating on the same amount of blood and oxygen that it was presurgery. Two theories. Don’t know which is right or if it’s something else entirely.

I do know that some cardio MD with fluid dynamics experience should do some research and figure out an equation to de-rate an EF measurement based on the amount of regurgitation. There’s a publishable paper there…

At any rate, he added digoxin to my carvedilol and lisinopril and told me not to worry and to come back in December or January for my next echo to see if there’s improvement. Fingers crossed.

Ron

 

[westie]

should improve

should improve

.
i thought that in the instance of mitral valve problems, reduced ef is a consequence of an enlarged/dialated left ventrical?

surgeon said my moderately dialated lv should/probably reduce in size over time post surgery, with no guarantees it would go back to normal.

over the last 2 years my lv has reduced in size and ef has returned to the lower range of normal.

while my blood pressure would not need medication in a heart disease free situation, the cardiologist put me on 5mg of inhibace daily to "strengthen the heart" and as our gp says, to reduce the load on the on-x valve

it seems i still have the potential for futher improvement in lv size and ef but absolutely no guarantees.

but this really underscores the need for EARLY SURGERY. with hindsight i should have hit the now button for surgery after my condition had declined to severe regurgitation because i am sure my heart went downhill in the following 8 months. both surgeon and cardiologist said there was no panic and that surgery over the next 12 months would do fine.

its like a turkey voting for a second christmas, but i should have demanded to see a surgeon when i was first diagnosed with mv prolapse, had surgery quickly and perhaps no lv and ef problems now

my guess, for what it is worth, is that in the absense of any other problems, your ef will improve over time, good luck.