Help with echo report

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R

roundsgirl

Well-known member
Joined
Dec 3, 2007
Messages
115
Location
South Carolina
Hey gang, I got the actual Echo report from last week.
OK who knows about peak and mean gradients?
My echo in June 08 My peak gradient was 31.14
My echo last week peak gradient was 59

Mean gradient June 08 18.2mmHg
Mean gradient last week 33mmHg

Does anyone knows what this means and why have the numbers gone up in such a short time? Is that bad?

Moderate aortic stenosis
Mitral inflow pattern is pseudonormal
Left atrial size is mildly dialiated.

I am going to call the Cardio. Mon. I promise, because my chest is still hurting, you all know that drill; as far as what a bad heart can make you feel like. I'm just kind of baffled right now as to what is going on with this tissue valve I have.
Any thoughts would be great.
Thanks guys
 
surface/chest echos are pretty inaccurate with the gradient thing. To my knowledge, the gradients are calculated on measurement estimates from numbers/formulas. I think this is a sensitivity issue of the machine.

A transesophageal echo would serve as a more accurate study while still being much lower risk than a catheterization (which to my knowledge is the most accurate).

If I were you and I felt like I was symptomatic and my gradient doubled in just a couple months, I'd ask for a TEE. No, I would demand a TEE, or I'd fire the cardiologist. There's almost ZERO risk for a TEE and the only detriment is the cost and the nasty taste of the numbing gel they make you gargle/eat.
 
YEP, first thing Monday Morning, call your Cardio and ask for a possible explanation for that rapid rise in gradient. A rise like that in only a few months needs to be explained.

If he doesn't offer to do more tests ASAP, then BUG Him to either give you a credible explanation NOW or to order whatever tests he thinks he needs to make a credible assessment.
 
Gradients

Gradients

Roundsgirl,

Sorry to hear about your troubles.

A few thoughts on gradients.
For gradient measurements, there is no benefit from having a TEE (TTE is actually more accurate, cath is the best, but not warranted here.) TEE is more useful to assess structure and lealfet function (you may need this now to see about the thrombus issue.)

Your cardiologist needs to find out what is going on here. The most likely causes are thrombus, pannus, or endocarditis. Endocarditis can be sub clinical and culture negative on about 30% of cases.

It is most important to look at thrombus as a cause right now. Did you take 90days of coumadin after surgery? (Not likely as you mentioned a Hx of bleeding..) The workup of a high gradient is routine.

Has anyone looked to see if you have PPM (patient Prosthesis mismatch?)

If you PM your height, weight, and valve size I can check that for you. Your echo report also gave an Aortic Valve Area (AVA?) which would be useful.

Good luck with the workup.
 
Use TEE to Check for Strands Also

Use TEE to Check for Strands Also

In addition to the blood clots, scar tissue formation, and infection just mentioned, there is another problem that only TEE will detect: valvular strands. These extremely fine, hair-like growths can be difficult to detect even with TEE.

Valvular strands and endocarditis both have the potential to send a shower of particles to the brain, causing injury to multiple areas of the brain.

Valvular strands were the cause of my husband's extensive stroke, when some of them broke free of the valve. Those that remained were found by TEE after his injury.

There are a few reports in the medical literature about strands, but generally they have not been found until after someone has had a stroke.

If this were myself or my loved one, I would want a TEE to look for everything possible that might be wrong, including strands. The eyes that look at the TEE must be very skilled in order to detect valvular strands.

Here is a comprehensive paper on TEE evaluation of prosthetic valves

http://bicuspidfoundation.com/Evaluation_of_Prosthetic_Heart_Valves_Van_den_Brink.pdf

Best wishes,
Arlyss
 
Thanks guys,
I called the Cardio. this morning they had told me to come in at 1:45 today but they just called and told me to come in right now. I'll check back in when I get back.

Thanks again, I'll be in touch.
Lisa
 
Strands have been found on both mechanical and tissue prosthetic valves. (Also have been seen on one's own native valve.)

I will double check the literature, but from memory they are found more often on mechanical than tissue valves, and more often in the mitral than in the aortic position. But remember, extremely little is known and published about them.

My husband's strands were on a mechanical valve in the aortic position. He had pannus also, on the sewing ring around the valve. The pannus was not impinging on the leaflet motion or negatively affecting the opening/closing of the valve in any way, and he had no cardiac symptoms. What was not known was the presence of strands, until after his stroke. When the strands formed is unknown.

Strands are thought to form for more than one reason and may be "blood-based" or collagen-tissue based. I suspect my husband had the collagen type, coming off the panus on the sewing ring - but it is impossible to know for sure - strands are not visible to the eye so pathology becomes extremely difficult.

So little is known and they are hard to detect - they should always be looked for when doing TEE on any prosthetic valve to determine cause of increased gradient. They need to be found before the stroke happens. The paper I posted was not yet published at the time this happened to my husband.


Best wishes,
Arlyss
 
I can only relate my numbers regarding gradient. I had a bicuspid aortic valve replacement with a mechanical valve nearly 6 months ago. I was told that a "normal" gradient was approximately 20. Mine was peaking at 115 which the echo technician kept saying "hmmm" and "wow" to when she was doing the reading. So a peak gradient of 59 isn't good but there have been others with significantly worse that made it through.
 
OK gang, So I went to the Cardio. yesterday. Blood pressure was high 140/106. We discussed the gradient levels he basically said it is a little high and we will watch them, but to put the whole meeting in summary " big girl with a little heart". I'm overweight and it's putting an extra load on my heart thus the higher gradient numbers, we really never discussed the stenosis other than that was contributing to the whole pressure issue. The whole problem with that is I have all kinds of other health issues also, back problems such as buldging disk laying on a nerve root, spinal stenosis, facet joint hypertrophy etc. 2 cyst in my brain which leaves me in bed lots of days with massive headaches, it just goes on and on. My cardio knows all of my health issues and actually deemed me 100% disabled once he sent me for a work performance elvaluation test. "Still no word on the disabillity.
So what he suggested is that I consult with a doctor who does gastric bypass or the lap band. He was really serious about this, so I'm having him write a letter stating such, to turn over to my lawyer. I was in shock, I know I'm heavy but dang.... plus I thought people with heart trouble were not even canidates for this kind of surgery, but he said no acutally it's allot of heart patients who can't exercise etc that have to have the surgery. Well this is not even an option for me right now, financially.
The new medicine he put me on is Exforge 5/160, do any of you have any comments about this med. I've never even heard of it.
So what do you think, this kind of blew me out of the water.
He did say that it is a possibilty that the valve they put in is to small, but there's not allot we can do about that right now, if it were to be the case.

Thanks for all of your input.
 
I don't totally 'buy' your Cardio's explanation.

YES, you have all those issues, BUT, have they changed since your surgery?

Your gradients have almost DOUBLED in 2 Months.
His explanation does NOT account for that CHANGE.

Personally, I would not waste any more time on that cardiologist. It's time to get a Second Opinion from a Cardiologist (or SURGEON) who understands valves.
IMO, Surgeons seem to have more interest and understanding of Valve Issues.

That said, I would recommend going to a known Major Heart Center such as DUKE in NC, or Emory in Atlanta, or Peachtree Cardiovascular in Atlanta.

Get copies of ALL of your Echocardiogram Reports and Tapes, Catheterization / Angiogram Reports and Tapes, and any other Test Results so that whoever you consult can view the actual procedure. Also get a copy of your Surgical Notes.

'AL Capshaw'
 
Thanks for your response. I don't totally buy the Gastro surgery either. I really don't know what to think at this point.

Do any of you know anything about the new med. he put me on Exforge 5/160.

I mentioned it before as I had never heard of it. I was on a drug called Bidil once for my heart, but it made my head feel as though it was going to explode, I'm hoping this drug isn't in that class of drugs. Needless to say I had to stop taking the Bidil.

I also forgot to mention that I have a hernia, it is right in between the breast. I had only noticed it last week when my chest starting hurting and I would apply pressure when I coughed and felt a large lump. Cardio said it's a hernia, no big deal. Given his response when I asked him to feel it; I take it that this is common after open heart surgery. I was just wondering anyone experience this after their surgery? I'm also wondering why the Chest Xray nor the CAT Scan made no mention of it, would it not show up on those test?

I apoligize for all the questions and not having any answers for others who post here. I'm just at a place I still feel just as bad as I did before the surgery, so at this point I can honestly say I wish I hadn't done it and I don't want to put fear or doubt in others. I guess I expected to feel better immediately, but no such luck so far.

Al, you mentioned some other hospitals, when and if I get my disability started I will seek other options, but right now it's just not possible for me.

Once again from the bottom of my "little" heart, I thank you all. It really helps to interact with people who have been through it all just like you have.
 
Hernia between the breasts....

I've never heard of that. Is it along the incision line?
Could it be a Hematoma (bleeding under / in the skin)?
That would strike me as more likely (but still NOT common). You may want to call your Surgeon's office and speak with one of his Nurses.

If it is a hematoma, it can take several weeks for the blood to be reabsorbed by the body (been there, done that, on the leg). Sorry about that.

'AL Capshaw'
 
Yep you got it; right along the incision. I know I searched hernia's last night and found most of them to be on the lower part of the scar. Like I said the Cardio didn't seem to concerned, but I'll give the surgeon a call later this morning. You can't see it, but can easily feel it; when I cough or stain etc.

Thanks again
 
When you talk with your Surgeon's Nurse, you might also want to bring up your latest Echo Result and ask if the surgeon has any idea why your gradients have almost doubled in the past 2 months. Hopefully that will be an 'easy' way to get a second opinion. Be sure to send him a copy of that report.
 
Hey again everyone. I hope this finds you doing well. Well, the actual Heart Surgeon called me back today, finally after 4 calls to his office. Anyway, about the hernia he also said he doesn't think it's a hernia, given the location. I am to go see him Wed. he wants to check the lump.

As far as the weight loss surgery, he was in total agreement with the Cardio. He felt that if would be an assest for me to proceed with the surgery. Which again left me kind of surprised. He said he doesn't recommend that anyone have any surgery that is not needed, but given my case he is 100% in agreement. I asked him if he felt this way; would he write me a letter stating why he felt this was necessary and what adverse affects it would have on my heart if I didn't proceed with this surgery. I've already got the Cardio writing a letter too. I will give all of this to my lawyer about the disabillity claim I have. Just trying to get my case in front of a judge asap. I'm telling you guys in South Carolina trying to get this disability even after my main specialist have deemed me 100% disabled is like pulling teeth.
He agreed about the gradient numbers being due to the stress on my heart from both the stenosis and the overload my heart is under due to the weight issue. He went into the spill about my heart being small and he used the largest replacement valve he could, which was 21mm. Once again expressing his regret that I could not have the mechanical valve, due to the bleeding issues.
I just wanted to update you guys and see what you think after this second opinion from the actual surgeon.

Take care and Happy Labor Day to all.
 
It sounds like you got a good second opinion from the surgeon.
I'm glad that he wants to look at your lump also.
All in all, that is probably as good a result as you could hope for given your situation. Good Luck with the Disability Claim. Giving a Denial the first time around seems to be par for the course, just to try to discourage the claimant. Hopefully this second letter will give your lawyer what he needs.

As Nancy says, "Never Give In and Never Give Up"!
 
Thanks to you all for your responses and suggestions. Oaktree, where do I start I don't even know what to think right now. When I see the surgeon on Wed. what do I need to ask him? Should I just come out and ask him if it's possible that the valve he put in is to small. I can never really get a straight answer from neither the Cardio. or Surgeon as to the stenosis. They both told me when they first saw it, we'll wait and see what the next echo looks like in 6 months, but obviously I had one done in less than six months. The Surgeon even said to me yesterday when I asked him should I be worried about the stenosis, no that if we lessen the load for my heart he expects my valve to last 8 to 10 years, and I asked myself how can he be so sure. He as the Cardio. said the gradients should go down as I lose the weight and load on my heart is lessened. So as I understand it the gradient rise is because of my weight issue, but why now I was just as "heavy" in May as in Aug., so as you can see I am still a bit confused. Being from a small town with no insurance is of no help to me right now, that's why I'm getting these letters to hopefully help move my disability along, so I have more choices.

Thanks again, I will let you know how things go. It's just hard to wrap my mind around all of this right now.

If anyone had ever suggested weight loss surgery I never would have thought it would be both of my heart doctors. Maybe when I get my letters from them it will give us more insight as to the reasons why they are pushing for this surgery. I will keep you posted.

There are not enough Thank You's out there to express my graditude for all of your concerns and input.
 
Oh yeah Oaktree, money is an issue. The surgeons office here is not considered a "center of excellence" yet which is a rating they have to have in order for any insurance I would get throught disablity to pay for the surgery. You have to so so many surgeries per year or something to get that rating, they told me there is a place in Lexington who is a center of excellence so the insurance if I ever get it would work there, but that's about an hour away, and what if something goes wrong or I have to travel there for each adjustment if a Lap Band were used.

The self pay discount for the surgeon here in town is $3500.00 up front, no charge for the first year's adjustments and $120.00 per adjustment after that. Plus I have to check with the hopsital to see if the indigent fund I am on there would cover the hospital part of it. Which if it comes down to it, I guess the doc.'s letters stating it is medically necessary instead of cosmetic maybe will help with that part of it.

Like I said I just don't know..............
 
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